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mimiciii-hospitalcourse-meta

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[ { "category": "Nursing/other", "chartdate": "2102-04-24 00:00:00.000", "description": "Report", "row_id": 1277863, "text": "NPN 1900-0700\n\nNeuro: Pt alert/oriented; MSO4 1mg X2 given this shift for leg pain with good results-pt has slept most of shift. Resp: On 2L NC with sats 99%; lungs clear, resp nonlabored breathing in 10's. CV: SR no ectopy, HR 90's; Neo gtt down to 0.2 mcg/kg/min with BP 97/44, 500cc NS bolus given last pm for CVP 4-current CVP 8-10. SVO2 65-75 this shift. K+ 6.1 at beginning of shift-IV insulin, Dextrose, Ca Gluconate, and Kaexylate given with K+ down to 4.7 at MN; lactic acid down to 3.6 at 0200 from 5.1-will recheck labs again at 0600. BLE very edematous with weak pulses. Afebrile-on IV abx. GI/GU: Abd round/distended; hypo BS. NGT to sx with light green drainage noted. Pt had LARGE soft stool this am. Foley with good u/o. Skin: intact; no breakdown noted. VSS; continues on sepsis protocol; cont to monitor and implement POC.\n" }, { "category": "Nursing/other", "chartdate": "2102-04-24 00:00:00.000", "description": "Report", "row_id": 1277864, "text": "pmicu nursing progress note\ncardiac: on sepsis protocol, but not on sepsis protocol! following svo2, but not bolusing when svo2<70%, unless ordered by physician and not drawing lactate level q4 hrs and chemistrys q 6 hrs. pt did receive one bolus of 500cc of normal saline when cvp approx 8 and svo2 was 66%, but no other boluses when svo2 < 70%. neo drip was weaned off by 12p and pt has maintained a bp of 107-114/50-63 with a pulse of 90-96 sr, no ectopy noted. cvp has been . K+ was 4.7. pt rec'd 2 gms of magnesium.\n\nresp: on room air with resp rate of and an o2 sat of 97-100%. lungs clear on the left but deminished at the right base. does become slightly short of breath with activity.\n\nid: unable to find source of infection. abdominal ultrasound today. one set of blood cultures sent from central line. temps of 96.8 po, 96.4 po. wbc was 12.2 with 7 bands. one levo, flagyl and vanco.\n\ngi: ascites (not firm). hypoactive bowel sounds. removed the ng tube-no aspirates were obtained when the ng tube was in place. given lasctulose and passed large soft, ob +, stool. tolerating clear liquid diet. elevated lfts slightly resolving.\n\ngu: urinary output approx 80-100cc/hr. bun 30 and creat 1.3.\n\nheme: pt 19.2, ptt 42.1, plts 101 and inr 2.4. hct 27.4--2 uprbc reserved in blood bank if eeded.\n\nmisc: legs very edematous and painful to touch to patient---rec'd a total of 1mg of morphine iv for bilateral leg pain. also scrotum swollen. sclera of both eyes jaundiced.\n\nendo: regular insulin sliding scale. received 8u at 12p.\n" }, { "category": "Nursing/other", "chartdate": "2102-04-23 00:00:00.000", "description": "Report", "row_id": 1277862, "text": "pmicu nursing admission note\npt arrived in the micu at approx 6P via ambulance from the ew accompanied with emts and nurse. upon arrival to the micu pt was alert and oriented. admission vitals were 98/43 with a pulse of 96 and a resp rate of 12 and temp of 98.3 ax.\n\nsystems review:\n\ncardiac: neo drip was increased from .61 mcg/kg/min to .73 mcg/kg/min and maintaining a bp of 100-108/45-47 with a pulse of 94-96sr. no ectopy noted. K+ was 6.1 on repeat blood--pt rec' in the ew. na 128. pt on sepsis protocol---svo2 was 77%. iv of normal saline infusing at 75cc/hr. extremities and scrotum very edematous. weak pedal pulses.\n\nresp: on 4l nasal prongs with a resp rate of and an o2 sat of 95-96%. lung sounds were deminished.\n\nid: temp was 98.3. wbc was 21.7. in the ew pt rec'd levo, flagyl and vanco.\n\ngi: abdomin soft/distended, ascites. positive bowel sounds. ng placed in ew, had coffee grounds. ng tube in place--at present clamped. elevated lfts.\n\ngu: urine output approx 60cc/hr. bun 37 and creat 1.7.\n\nheme: hct 29, plts 122. earlier blood: inr 2.2, pt 18.2, ptt 34 and plts 187.\n\nneuro: alert and oriented. difficult to understand--pt's primary language is french. also speech is somewhat garbled sounding. mouth is also dry.\n" }, { "category": "Radiology", "chartdate": "2102-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 819008, "text": " 9:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for PNA, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o Hepatitis C, cirrhosis, presents with fatigue,\n somnolence, leg pain.\n REASON FOR THIS EXAMINATION:\n please eval for PNA, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fatigue and somnolence.\n\n COMPARISON: \n\n Compared to the prior study NG tube has been inserted the tip of which is\n coiled in the stomach. Tip of the right IJ line is in distal SVC. The lungs\n are clear of focal infiltrate. The heart has an LV configuration but is not\n enlarged. Compared to the prior study the degree of pulmonary vascular\n congestion has decreased. There is a band of linear density at the right lung\n base most consistent with atelectasis.\n\n IMPRESSION: No focal infiltrate to suggest pneumonia. Likely bilateral lower\n lobe atelectasis.\n\n Improved CHF.\n\n" }, { "category": "Radiology", "chartdate": "2102-04-24 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 819024, "text": " 1:51 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: HEP C CIRRHOSIS UNDERGOING WORK UP FOR LIVER TXP PRESENTS WITH HYPOTENSION,ELEV WBC .EVAL FOR ASCITES\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with Hep C/cirrhosis undergoing w/u for liver txp presents\n with hypotension, elev WBC.\n REASON FOR THIS EXAMINATION:\n ? ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Hepatitis C and cirrhosis with hypotension and elevated WBC.\n Please assess for ascites.\n\n ABDOMINAL ULTRASOUND: Limited evaluation was made of the four quadrants of\n the abdomen. No ascites is present.\n\n IMPRESSION: No ascites.\n\n" }, { "category": "Radiology", "chartdate": "2102-05-03 00:00:00.000", "description": "CT 150CC NONIONIC CONTRAST", "row_id": 820021, "text": " 2:56 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: ALSO CT ABDOMENplease eval for change in chest mass, +/- asc\n Admitting Diagnosis: SEPSIS\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with Hep C and cirrhosis presented with worsening ascites,\n edema, jaundice and LE pain. New rapid rise in WBC concerning for lymphoma.\n REASON FOR THIS EXAMINATION:\n ALSO CT ABDOMENplease eval for change in chest mass, +/- ascites\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man with hepatitis C and cirrhosis who presented with\n worsening ascites, edema, jaundice, and lower extremity pain. He has an\n elvated white count concerning for pneumonia. Please evaluate for adenopathy\n or infection.\n\n TECHNIQUE: Axial images were obtained from the lung apices to the pubic\n symphysis after the administration of oral and intravenous contrast.\n\n CONTRAST: 150 cc of Optiray was administered due to the patient's\n hypertension.\n\n COMPARISON: CT of the abdomen from and a CT of the chest\n from .\n\n CT OF THE CHEST WITYH CONTRAST: Again there is pretrachial, precarinal and\n subcarinal adenopathy. The subcarinal adenopathy currently measures 3.5 x 2.8\n cm. This is not changed significantly compared to the prior examination using\n a comparable level. The pretracheal lymph node measures 2 cm in short axis,\n previously 2.2 cm. This is likely not a significant difference. There is no\n new adenopathy. The heart and great vessels are within normal limits. There\n are no pericardial or pleural effusions. On lung windows, two of the\n previously reported nodules are no longer present. One has decreased in size\n and is barely visible. This one is located in the right upper lobe laterally.\n There are no parenchymal consolidations concerning for pneumonia.\n\n CT OF THE ABDOMEN WITH CONTRAST: Again there is a nodular appearance to the\n liver consistent with cirrhosis. There is a large gallstone. There is\n splenomegaly. There are small periportal lymph nodes none of which\n individually meets size criteria for pathologic enlargement. The pancreas\n contains a 7 mm hypodense nonenhancing cyst in the tail. This is unchanged\n from the recent prior examination. The adrenals and kidneys appear normal. The\n bowel loops are unremarkable. There is no intra-abdominal free fluid.\n\n CT OF THE PELVIS WITH CONTRAST: There is no pelvic free fluid. The colon is\n diffusely filled with stool. There is a small amount of air within the urinary\n bladder. There is a small left inguinal hernia which does contain a small\n bowel loop.\n\n (Over)\n\n 2:56 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: ALSO CT ABDOMENplease eval for change in chest mass, +/- asc\n Admitting Diagnosis: SEPSIS\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Bone windows demonstrate no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. Stable adenopathy within the mediastinum. Near-complete resolution of the\n previously reported pulmonary nodules.\n 2. Nodular liver and splenomegaly compatible with patient's history of\n cirrhosis.\n 3. Air within the urinary bladder, presumably due to recent instrumentation.\n 4. Small left inguinal hernia which contains a small bowel loop. This is\n nonobstructing.\n\n" }, { "category": "Radiology", "chartdate": "2102-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 818941, "text": " 12:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for cardiopulmonary pathology.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o Hepatitis C, cirrhosis, presents with fatigue,\n somnolence, leg pain.\n REASON FOR THIS EXAMINATION:\n Evaluate for cardiopulmonary pathology.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fatigue. History of hepatitis C and cirrhosis.\n\n COMPARISON: Chest CT of .\n\n FINDINGS: AP semi-upright view. Accounting for technique, the heart and\n pulmonary vessels are within normal limits. The right paratracheal stripe\n appears prominent, consistent with known mediastinal lymphadenopathy described\n on the chest CT. Multiple pulmonary nodules described on the chest CT are not\n detected on the current study. There is no pleural effusion. The visualized\n soft tissues and osseous structures are unremarkable.\n\n IMPRESSION: 1) No evidence of an acute infection.\n 2) Mediastinal lymphadenopathy as seen on the recent chest CT.\n 3) Multiple pulmonary nodules seen on the recent chest CT are not identified\n by this technique.\n\n" }, { "category": "Radiology", "chartdate": "2102-04-23 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 818951, "text": " 3:24 PM\n PORTABLE ABDOMEN Clip # \n Reason: Evaluate NGT placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with hepatitis C, cirrhosis, here with sepsis. PLease eval re\n NGT placement and any other pertinent findings.\n REASON FOR THIS EXAMINATION:\n Evaluate NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Status post nasogastric tube placement.\n\n ABDOMEN, TWO VIEWS: The nasogastric tube terminates below the diaphragm, in\n the left upper quadrant. The bowel gas pattern is nonspecific. The visualized\n osseous structures are unremarkable.\n\n Congestive heart failure and a right IJ central venous line are again seen.\n Please refer to the chest film of the same day for further detail.\n\n IMPRESSION: Satisfactory position of nasogastric tube.\n\n" }, { "category": "Radiology", "chartdate": "2102-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 818948, "text": " 2:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt who had central line placed,please eval placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o Hepatitis C, cirrhosis, presents with fatigue,\n somnolence, leg pain.\n REASON FOR THIS EXAMINATION:\n pt who had central line placed,please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post central line placement.\n\n COMPARISON: AP upright view done 90 minutes earlier.\n\n AP SUPINE VIEW: The right internal jugular venous catheter terminates in the\n distal superior vena cava. There is no pneumothorax. There is interval\n development of bilateral interstitial and perihilar opacities, consistent with\n pulmonary edema. The heart appears unchanged. A thick right paratracheal\n stripe is again noted, representing mediastinal lymphadenopathy. There is no\n pleural effusion. The visualized soft tissues and osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. Interval development of moderate congestive heart failure.\n 2. Satisfactory position of central venous catheter. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2102-05-04 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 820117, "text": " 2:13 PM\n MR W &W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: B/L LE PAIN B/L HYPERREFLEXIA\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with HCV cirrhosis, mediastinal LAD, b/l LE pain, b/l\n hyperreflexia on exam\n REASON FOR THIS EXAMINATION:\n Please do dedicated thoracic per neuro\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Lower extremity pain, hyperreflexia, patient with\n cirrhosis and mediastinal lymphadenopathy.\n\n MRI OF THE THORACIC SPINE WITH GADOLINIUM:\n\n TECHNIQUE: T1, T2 and STIR sequences before and after the administration of\n gadolinium.\n\n FINDINGS: There is no evidence of cord compression. There is no evidence of\n abnormal cord morphology or signal. There are small hemangiomata within the\n bodies of T7 and T5. The signal is otherwise preserved.\n\n IMPRESSION: No evidence of cord compression or abnormal cord signal.\n\n" }, { "category": "Radiology", "chartdate": "2102-04-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 819516, "text": " 11:26 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate. comment on atelectasis and/or effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with Hep C/cirrhosis and large mediastinal mass concerning for\n malignanyc. had fever to 101.4 on abx overngiht.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate. comment on atelectasis and/or effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST:\n\n HISTORY: Cirrhosis and mediastinal mass with fever.\n\n Heart size is normal. Right paratracheal mass again demonstrated. There is a\n density consistent with atelectasis in the right lower zone and linear\n atelectasis at the left base. No confluent air space consolidation.\n\n IMPRESSION: Slightly more prominent atelectasis in right lower zone since\n prior film of . Linear atelectasis left base. No definite pneumonia.\n Right paratracheal mass.\n\n" }, { "category": "ECG", "chartdate": "2102-04-23 00:00:00.000", "description": "Report", "row_id": 186542, "text": "Baseline artifact. Resting sinus tachycardia. SI-S2-S3 pattern with prominent\nterminal S waves in the lateral chest leads is noted. Finding is non-diagnostic\nbut may abe seen with right ventricular overload. Slow initial R waves\nprogression in leads VI-V2. Possible minor right ventricular conduction delay\nas well. Slight ST segment elevations in lead V2 are non-specific. Exclude\nischemia if clinically indicated. Left axis deviation consistent with left\nanterior fascicular block. No previous tracing available for comparison.\nClinical correlation is suggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-04-26 00:00:00.000", "description": "Report", "row_id": 1277869, "text": "NPN 0700-1900\n\nNeuro: A&O X3, very pleasant and cooperative. MAE's but difficulty moving legs due to increased pain with activity. C/O bilateral leg pain up to . MSO4 given in am then switched to oxycodone with fair relief. Continues on neurontin.\nCV: NBP 112-125/60-74, mean 77-90; HR 63-93, NSR, no ectopy. 3+ edema BLE. 40meq KCL given for K of 3.3; Mag repleted also. PIV placed R arm, RIJ d/c'd.\nResp: O2sat 97-99% on RA, respirations regular, unlabored. Lung sounds clear.\nGI: Abdomen soft, ND, NT, +BS, large loose BM X 1 today after getting lactulose. Advanced to diabetic diet, tolerated well, good apetite.\nGU: Foley catheter is draining clear amber urine. Output increased after getting spironalactone. 800cc out this shift.\nEndo: FSBG in the 200's requiring coverage with humalog insulin. See carevue for exact numbers. Glipizide restarted and given in afternoon when available.\nA/P: Liver cirrhosis/plan to transfer to transplant floor, ? if candidate for transplant.\nA/P: Leg pain/Neurontin as ordered, oxycodone prn.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-04-25 00:00:00.000", "description": "Report", "row_id": 1277865, "text": "MICU/SICU, NPN:\nNeuro: A&OX3 throughout shift. PERRLA @ 3mm, MAE independently but very deconditioned. Received 6mg IV MSo4 for R anterior thigh pain over this shift.\n\nCV: HR 70's NSR w/o ectopy. SBP 110's. 3+-4+ edema to LE's. CVP 5-10.\n\nResp: O2Sats mid 90's on RA. Clear upper lobes, diminished @ bases. Bx back from mediastinal lymphadenopathy- results negative for malignancy.\n\nHeme/lytes/micro: Awaiting a.m. labs. Blue top sent but coags. not ordered so may be added on later. Results of . stim. test are + for adrenal insufficiency. FSBG qid. Vanco./Flagyl/Levo. for ? unknown source of infection.\n\nGI: Tolerates clears. +BS. Has had 2 loose brown BM's this shift. Trace guiaic +. Liver service following, is on liver transplant list.\nAbd. U/S done yesterday - for ascites.\n\nGU: Foley to gravity draining clear amber urine.\n\nDerm: D&I.\n\nSocial: FULL CODE. Multiple family members visiting o/n. Dgtr. is a nurse and asks appropriate questions. ? call out today.\n" }, { "category": "Nursing/other", "chartdate": "2102-04-25 00:00:00.000", "description": "Report", "row_id": 1277866, "text": "nursing progress note see careview for details.\n\nNeuro:Awake,alert,oriented x3.pupils perl follows commands and moves all extremites with appears equal strenght.pt is very deconditioned, due to abd ascites and leg edema it is difficult for him to move.Pt complains of anterior thigh pain on right and bil leg pain.Pain has been treated with ms dose has been increased.\n\ncv:Remains in nsr hr 70 to 74 without ectopy.Systolic bp stable 110 to 120,diastolic bp 50 to 57,map 71 to 80.No temp spikes today.Bil leg edema present,feet warm with palpable dp and pt pulses present.\n\nresp:Remains on no o2,spo2 99% on room air.Resp rate 20 to 24,spo2 99%.breath sounds clear but diminished bibasilar.\n\ngu:Foley cath to cd draining clear amber urine in good amounts,\n\ngi:Abd large with ascites present.Had 2 large soft brown stools today.Tolerating full diabetic diet.\n\nendocrine:Blood sugars elevated treated with humalog sliding scale insulin.\n\nsocial:full code.Pt ha made multiple phone calls to family members.\nplan:Pt remains on liver transplant list.\n transfer to floor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-04-25 00:00:00.000", "description": "Report", "row_id": 1277867, "text": "SMICU nsg progress note\nS/O Alert and oriented. Pt states pain in legs much improved refusing additional ms04 at this time. Able to ambulate around bed with one assist. OOB to chairx 1hr. Bp/hr remain stable with sats 98-99% on ra.\nA/p Cont to improve. Pt called out to renal transplant floor.\n" }, { "category": "Nursing/other", "chartdate": "2102-04-26 00:00:00.000", "description": "Report", "row_id": 1277868, "text": "npn\nneuro: pt aox3 very pleasant man speech is very low and at times is difficult to understand but pt is able to make needs known . pt needs to be encouraged with making needs known to staff (he doesn't want to bother anyone).\npain: pain med x2 for lfet side pain and leg pain with good effect.\ncad vss hr 80-60's b/p 117-112/60's\nresp ls clear sats 100-98% on ra\ngi: ascites present. pt tolerating clear liquids i.e. jello. no bm over night\ngu: foley patent draiing amber clear urine at 60cc/hr\nid afebrile.\nplan: pt is to be transferred to reanl transplant floor for cont. of care.\n" } ]

[ { "category": "Radiology", "chartdate": "2122-09-27 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1208849, "text": " 1:09 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n CHEST FLUORO WITHOUT RADIOLOGIST\n Reason: HEART CATH. INSERTION\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: catheter insertion.\n\n FINDINGS: In comparison with the earlier study of this date, there is little\n change in the appearance of the intraaortic balloon and endotracheal tube and\n nasogastric tube. Further information can be gathered from the procedure\n report.\n\n" }, { "category": "Radiology", "chartdate": "2122-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1209295, "text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for edema and opacity\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with alcoholism presents from osh with vfib arrest and STEMI\n now with RLL opacity\n REASON FOR THIS EXAMINATION:\n please evaluate for edema and opacity\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8 A.M. \n\n HISTORY: 42-year-old man with alcoholism. V fibrillation arrest and MI.\n Right lower lobe opacity.\n\n IMPRESSION: AP chest compared to through 27:\n\n Mild interstitial pulmonary edema predominantly in the right upper lung is\n new. The large right lower lobe consolidation most likely aspiration\n pneumonia is stable, now accompanied by at least a small if not larger right\n pleural effusion. Intra-aortic balloon pump has been removed. Ascending\n Swan-Ganz rotation catheter ends in the right descending pulmonary artery. ET\n tube in standard placement. Nasogastric tube loops in the upper stomach. No\n left pleural effusion. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208847, "text": " 12:11 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?PTX\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with cardiogenic shock and vfib arrest\n REASON FOR THIS EXAMINATION:\n ?PTX\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cardiogenic shock, evaluate for pneumothorax.\n\n The position of the endotracheal tube and intra-aortic balloon is unchanged.\n Some clearing of the upper zones on each side is present suggesting resolving\n failure.\n\n IMPRESSION: Lungs clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208801, "text": " 10:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna/ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p arrest\n REASON FOR THIS EXAMINATION:\n eval for pna/ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old male status post cardiac arrest.\n\n COMPARISON: None available in the system.\n\n PORTABLE SUPINE CHEST RADIOGRAPH: The endotracheal tube terminates 6.6 cm\n above the level of carina. A nasogastric tube courses below the diaphragm,\n though the tip is incompletely imaged. The side port of the nasogastric\n catheter appears to be above the diaphragm and advancement is recommended.\n There is symmetric diffuse opacification of the upper lung zones and\n thickening of the minor fissure on the right, findings suggestive of flash\n pulmonary edema. No focal consolidation or pneumothorax is identified. There\n is no apparent pleural effusion. The cardiac size is within normal limits.\n\n IMPRESSION:\n 1. Diffuse biapical opacification, findings consistent with flash pulmonary\n edema. No pneumonia or pneumothorax.\n 2. Standard position of endotracheal tube.\n 3. Side port of nasogastric tube above the diaphragm. Advancement is\n recommended.\n Dr. communicated the lines and tube position and advancement\n recommendations to Dr. at 5:48 a.m. on by\n telephone.\n\n" }, { "category": "Radiology", "chartdate": "2122-09-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208939, "text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Line and ETT placement\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old male with V-fib arrest status post line placement and\n ET tube placement.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: A Swan-Ganz catheter from an inferior approach\n terminates in the expected region right inferior pulmonary artery. There is\n new dense opacity at the right lung base which could represent an\n atelectasis/right lower lobe collapse, but infarct cannot be excluded given\n the position of the pulmonary artery catheter. Aspiration is also possible,\n but infection is considered less likely given the abrupt interval development.\n\n The endotracheal tube terminates 6.5 cm above the carina. The radiopaque tip\n of the aortic balloon pump catheter terminates 2.8 cm below the superior\n margin of the aortic arch. Nasogastric tube follows a normal course at the\n left side port beyond the GE junction.\n\n There is mild interstitial edema. Heart size is top normal. Mediastinal\n silhouette is normal. There is no pneumothorax.\n\n Findings discussed by phone with Dr. at 9:50 am on .\n\n" }, { "category": "Radiology", "chartdate": "2122-09-28 00:00:00.000", "description": "LP ANKLE (AP, MORTISE & LAT) LEFT PORT", "row_id": 1208940, "text": " 8:22 AM\n ANKLE (AP, MORTISE & LAT) LEFT PORT Clip # \n Reason: any fracture?\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old male etoh hx admitted for vfib arrest, Left leg with previous\n surgery, worsening swelling, unknown if experienced trauma\n REASON FOR THIS EXAMINATION:\n any fracture?\n ______________________________________________________________________________\n WET READ: EHAd MON 5:00 PM\n 1. No acute fracture.\n 2. ORIF of old distal fibular fracture without hardware complications.\n 3. Old healing fracture of distal tibia.\n 4. Tibiotalar joint large osteophytosis and narrowing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old male with left leg swelling. Evaluate for fracture.\n\n COMPARISONS: None.\n\n FINDINGS: Three views of the left ankle were obtained. The patient is status\n post ORIF of a an old distal left fibular fracture, with lateral plate and\n interlocking screws. Hardware is intact, in proper position and without signs\n of complication. An old fracture is also noted of the distal tibia, with\n narrowing and large osteophytosis of the tibiotalar joint. An ankle joint\n effusion and soft tissue swelling are seen. No new fracture or dislocation is\n identified.\n\n IMPRESSION:\n 1. No acute fracture.\n 2. ORIF of old distal fibular fracture without hardware complications.\n 3. Old healing fracture of distal tibia.\n 4. Tibiotalar joint osteophytosis and narrowing.\n\n" }, { "category": "Radiology", "chartdate": "2122-09-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1209101, "text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate progression of RLL infiltrate\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with a reported hx of alcoholism but no know cardiac history\n admitted from osh with vfib arrest and STEMI, currently intubated\n REASON FOR THIS EXAMINATION:\n evaluate progression of RLL infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Portable semi-erect radiograph of chest.\n\n Comparisons were made with prior chest radiographs through \n with the most recent from .\n\n FINDINGS: The Swan-Ganz catheter has been minimally retracted with the tip\n more proximally located though still in the right main pulmonary artery.\n Position of other monitoring and supporting devices are in standard place.\n\n Since , large right lower lung opacity which was new is less\n dense and has minimally decreased in size and most likely explains aspiration\n as the cause. Left lower lung opacity, presumably atelectasis has improved.\n There are no new opacities of concern.\n\n Mediastinal and hilar contours are unchanged.\n\n IMPRESSION: Since , large right lower lung opacity which was\n new and most likely aspiration, has decreased in size as well as in the\n density.\n\n" }, { "category": "Echo", "chartdate": "2122-09-27 00:00:00.000", "description": "Report", "row_id": 91511, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 73\nWeight (lb): 225\nBSA (m2): 2.26 m2\nBP (mm Hg): 91/63\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 11:26\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Severely depressed LVEF. Cannot exclude LV mass/thrombus. No\nVSD.\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nOverall left ventricular systolic function is severely depressed (LVEF < 20\n%). A left ventricular mass/thrombus cannot be excluded. There is no\nventricular septal defect. Right ventricle appears normal in size with\nborderline normal free wall function. Mild (1+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2122-09-27 00:00:00.000", "description": "Report", "row_id": 91512, "text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease.\nHeight: (in) 73\nWeight (lb): 225\nBSA (m2): 2.26 m2\nBP (mm Hg): 125/97\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 04:34\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: RV function depressed. Abnormal septal motion/position.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: TR present - cannot be quantified.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nPoor image quality. LV systolic function appears depressed. RV with depressed\nfree wall contractility. There is abnormal septal motion/position. Mild (1+)\nmitral regurgitation is seen. Tricuspid regurgitation is present but cannot be\nquantified. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2122-09-29 00:00:00.000", "description": "Report", "row_id": 91926, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function. Right ventricular function.\nHeight: (in) 68\nWeight (lb): 224\nBSA (m2): 2.15 m2\nBP (mm Hg): 106/59\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 14:35\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferior -\nakinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic; inferior apex - akinetic; lateral apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Physiologic MR (within normal\nlimits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is moderate regional left ventricular\nsystolic dysfunction with inferior/inferolateral akinesis and anteroseptal\nhypokinesis/akinesis (LVEF approximately 35 percent). Right ventricular\nchamber size is normal. with normal free wall contractility. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Physiologic mitral regurgitation is seen (within normal limits). There\nis borderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared to , left ventricular function appears less depressed but\nviews are suboptimal for comparison.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208809, "text": " 4:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess ETT placement\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with vfib arrest, STEMI, intubated\n REASON FOR THIS EXAMINATION:\n Please assess ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: V fib arrest, intubated, assess ETT position.\n\n CHEST:\n\n The endotracheal tube lies 8 cm from the carinal angle and should be advanced.\n The position of the nasogastric tube is unchanged with the sidehole lying\n within the esophagus.\n\n An intraaortic balloon pump is present opposite the fifth vertebral body.\n\n The heart is not enlarged. Increased opacities are present in both the upper\n lobes and atelectasis is present on the right. Appearances are probably due\n to pulmonary edema though the distribution is unusual.\n\n IMPRESSION: Both endotracheal tube and nasogastric tube can be advanced.\n Elevation of minor fissure with subsegmental atelectasis, probable fluid\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-10-01 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1209535, "text": " 5:19 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Is there a c-spine injury?\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man who had cardiac arrest and fell, in a C-collar now, unsure if\n there is damage to C-spine\n REASON FOR THIS EXAMINATION:\n Is there a c-spine injury?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:20 PM\n 1. No evidence of acute fracture or malalignment.\n\n 2. Moderate right pleural effusion with evidence of mild interstitial\n pulmonary edema.\n\n 3. Scattered air-fluid levels throughout left mastoid air cells. Recommend\n clinical correlation.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac arrest and fall, now in a cervical collar.\n Unsure if there is damage to the cervical spine. Please evaluate for C-spine\n injury.\n\n TECHNIQUE: MDCT axial images were acquired through the cervical spine without\n administration of intravenous contrast material. Multiplanar reformations\n were performed.\n\n COMPARISON: None.\n\n FINDINGS: There is no evidence of acute fracture or malalignment. No\n prevertebral soft tissue edema or hematoma is seen. The visualized portion of\n the aerodigestive tract is grossly unremarkable. Multiple small bilateral\n cervical lymph nodes do not meet CT size criteria.\n\n There is at least a moderate right pleural effusion. Secondary interlobular\n septal thickening seen in the lung apices are consistent with mild pulmonary\n edema. The thyroid gland is grossly unremarkable. Scattered air-fluid levels\n are seen within left mastoid air cells. The visualized portions of the right\n mastoid air cells are well aerated. A mucus retention cyst is seen within the\n left maxillary sinus.\n\n IMPRESSION:\n\n 1. No evidence of acute fracture or malalignment.\n\n 2. Moderate right pleural effusion with evidence of mild interstitial\n pulmonary edema.\n\n (Over)\n\n 5:19 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Is there a c-spine injury?\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Scattered air-fluid levels throughout left mastoid air cells. Recommend\n clinical correlation.\n\n Dr. discussed with Dr. via telephone at 06:16 p.m. on , .\n\n" }, { "category": "ECG", "chartdate": "2122-09-26 00:00:00.000", "description": "Report", "row_id": 248849, "text": "Sinus rhythm. Acute inferior-posterior myocardial infarction pattern. Compared\nto the previous tracing there is no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2122-10-02 00:00:00.000", "description": "Report", "row_id": 248846, "text": "Normal sinus rhythm. Left atrial abnormality. Possible old inferior myocardial\ninfarction. Compared to the previous tracing of there is no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2122-09-27 00:00:00.000", "description": "Report", "row_id": 248847, "text": "Sinus rhythm. Slight intraventricular conduction delay. Tiny likely\nclinically insignificant inferior Q waves. Delayed precordial R wave\nprogression. QS fractionation in leads V1-V3 raises suspicion of a prior\nanteroseptal myocardial infarction. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2122-09-26 00:00:00.000", "description": "Report", "row_id": 248850, "text": "Sinus tachycardia. Inferior ST segment elevation with anterior ST segment\ndepression consistent with acute inferoposterior myocardial infarction. No\nprevious tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2122-09-27 00:00:00.000", "description": "Report", "row_id": 248848, "text": "Sinus tachycardia. Compared to the previous tracing there is no diagnostic\nchange.\nTRACING #3\n\n" } ]

[ { "category": "Echo", "chartdate": "2165-01-03 00:00:00.000", "description": "Report", "row_id": 103018, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for Congestive heart failure, cardiogenic shock. Hypotension and pulmonary edema..\nHeight: (in) 66\nWeight (lb): 120\nBSA (m2): 1.61 m2\nBP (mm Hg): 82/59\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 11:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Normal regional and global biventricular systolic function. No\npathologic valvular abnormalities.\n\n\n" }, { "category": "ECG", "chartdate": "2165-01-01 00:00:00.000", "description": "Report", "row_id": 311846, "text": "Artifact is present. Sinus rhythm with sinus arrhythmia. Non-specific\nST-T wave changes. Compared to the previous tracing of ST-T wave\nchanges are more prominent.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769691, "text": " 10:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: etiology of high o2 requirement, ? chf, effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p MI w/ increased oxygen requirement\n REASON FOR THIS EXAMINATION:\n etiology of high o2 requirement, ? chf, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: High oxygen requirement.\n\n PORTABLE AP CHEST: No prior studies are available for comparison.\n\n The patient is markedly rotated towards the right, limiting assessment of\n cardiac and mediastinal contours. However, the heart is probably enlarged even\n accounting for this factor. The pulmonary vascularity appears indistinct and\n there is a subtle interstitial pattern bilaterally. No confluent areas of\n consolidation are seen in either lung and no definte pleural effusions are\n visualized.\n\n The bones appear demineralized.\n\n IMPRESSION: Findings suggest of CHF with interstitial edema. Followup\n nonrotated radiograph is suggested when the patient's condition permits in\n order to better assess the mediastinum.\n\n" }, { "category": "Echo", "chartdate": "2153-10-09 00:00:00.000", "description": "Report", "row_id": 72693, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 60\nWeight (lb): 120\nBSA (m2): 1.50 m2\nBP (mm Hg): 109/41\nStatus: Inpatient\nDate/Time: at 10:42\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nOverall left ventricular systolic function is moderately depressed. There is\nno resting left ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. There is focal hypokinesis of the apical\nfree wall of the right ventricle.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is moderate mitral annular calcification. There\nis moderate thickening of the mitral valve chordae. The tips of the papillary\nmuscles are calcified. There is no significant mitral stenosis. Moderate to\nsevere (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. There is\nno triscupid stenosis. Moderate to severe [3+] tricuspid regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets are thickened.\nThere is no pulmonic valve stenosis. Significant pulmonic regurgitation is\nseen. The main pulmonary artery and its branches are normal. No color Doppler\nevidence for a patent ductus arteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Overall left ventricular systolic function is\nmoderately-to-severely depressed (ejection fraction 30-40 percent) secondary\nto severe hypokinesis of the midventricular and apical segments of the\nanterior septum and anterior free wall. Right ventricular chamber size is\nnormal. There is focal hypokinesis of the apical free wall of the right\nventricle. The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. There is moderate\nthickening of the mitral valve chordae. Moderate to severe (3+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. The supporting structures of the tricuspid\nvalve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. The\npulmonic valve leaflets are thickened. Significant pulmonic regurgitation is\nseen. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2153-10-08 00:00:00.000", "description": "Report", "row_id": 170765, "text": "Sinus rhythm\nProbable old septal infarct\nLeft atrial abnormality\nLow limb leads voltage\nLateral T wave changes are nonspecific\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2153-10-09 00:00:00.000", "description": "Report", "row_id": 170766, "text": "Sinus rhythm\nShort PR interval\nLong QTc interval\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing, wide pread T wave inversion consider global ischemia,\nmetabolic derangement, central nerve system event\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2153-10-10 00:00:00.000", "description": "Report", "row_id": 1425413, "text": "Discharge summary Note:\n\nPt cont to be confused. Sleeping throughout the night, received 50mg po trazadone @ HS with good effect. Family in last night to visit.\n\nResp: Pt on 3L NC. LS clear, dim at bases. SPO2 94-98%. No resp distress noted.\n\nCV: Tele: NSR with occ PVC's, VSS, please see carevue. At 2400 pt received 40meq PO KCL, 400mg mag oxide and 1 pkt neutra phos. for low nl K and mag, phos lab values. See carevue. No C/O chest pain. Pt on PO lopressor and tol well. Pulses audible with DP, R groin dressing in place C/D/I with sm ecchymosis secondary to cardiac cath.\n\nGI/GU: Pt on low sodium cardiac diet and reported to have poor appetite. Need to encourage PO intake. Foley in place and draining pink, sm hematuria, At 0100 pt received 40mg IV lasix for urine o/p 30cc/hr and with + diuresis.\n\nPlan:\nPt t/b transfered to floor\nMonitor VS, pulm and neuro status\nNotify daughter of transfere \n" }, { "category": "Nursing/other", "chartdate": "2153-10-09 00:00:00.000", "description": "Report", "row_id": 1425410, "text": "7p-7a Nursing Note:\nPt s/p AMI, stent to LAD\n\nNeuro: Pt confused, oriented to self and at times to place. Obeys and follows commands. MAE. Pt pulling off O2 and pulling at IV tubing, wrist restraints applied. Frequent orientation.\n\nResp: Maintained on 5L NC. LS Ins/Exp wheezes. SPO2 93-97%. NO resp distress noted.\n\nCV: Tele: NSR with occ PAC's/PVC'S. No c/o chest pain. NBP 100's-120's/60-70's. Pt cont on lopressor 25mg PO BID, tol well. PO captopril d/c'd. Integrilin d/c'd at 0600 and IVF cont at 75ml/hr for 1 more liter via L AC. R groin C/D/I with DSD and ecchymosis. No hematoma noted. Distal pulses audible with DP.\n\nGI/GU: Pt on low sodium, cardiac diet- reported to have poor appetite. PO meds taken without diff. Abd soft, +BS. No BM this shift. Foley in place draining amber urine with some hematuria noted. Urine o/p <30cc/hr. MD made aware and came to unit, no orders received.\n\nPlan:\nMonitor VS, neuro and pulm status, monitor for CP/EKG changes. Freq orientation... Monitor urine o/p and pending am labs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-10-09 00:00:00.000", "description": "Report", "row_id": 1425411, "text": "CCU NSG NOTE: R/I MI/ SP STENT\nS: \"After his surgery he'd probably like some cookies so I'm just going to go get a few\".\nO: For complete VS see CCU flow sheet.\nCV: Pt symptom free. HR 60-70NSR on 25mg lopressor. BP 95-1-teens/50s. Captopril not yet started. Groin dry, but eccymotic. Pulses dopplerable.\nHEME: Crit dropped 10p since admission. Afternoon crit will be drawn to ensure she is stable.\nRESP: Sat ~93% in am on 5L now up to 98% on same fi02.CXR pending.\nRENAL: Urine output poor with very consentrated urine. IVF stopped at 11am. Pt ~1 liter positive for the day.\nGI: Pt has poor apetite, but taking some pos with encouragement.\nMS: Pt remains disoriented with poor short term memory. She remains quite pleasant and cooperative for as long as her memory lasts.She has not slept since admission and remains very busy--wanting to clean, go shopping, visit her parents. She needs to be posied as she will get up and is unsafe to do so. PT has been consulted to bring pt walker.\nA: Stable post MI/stent\nP: Keep pt safe despite disorientation. Check results of X-ray re- diuresis or fluid bolus. Monitor groin/pulses. Check labs at 6pm. Reorient frequently. Keep patient posied.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-09 00:00:00.000", "description": "Report", "row_id": 1425412, "text": "D: Pt. remains up in chair with daughters at bedside. Pt. denies CP/SOB or other distress. Please see careview data and assessment.Pt is pleasantly confused with posesy waist restraint in place to prevent fall.\n\nP: Continue full support, transfer as previously ordered when bed is available.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-08 00:00:00.000", "description": "Report", "row_id": 1425409, "text": "CCU NSG NOTE: S/P STENT\nS: \"I live with my father, he's 110 and sharp as a whip\".\nO: CV: Pt has remained pain free. HR has been in 80-90s NSR with occasional pacs and PVCs. BP has been stable in 140-130/60-70s. She received her first dose of captopril 12.5 and has tolerated it. She continues on integrelin at 1mic/kilo until 6am . Sheathes were pulled at 14:30 in cath lab and groin remains dry with no ooze or hematoma and all pulses are dopplerable. Feet are cool CSM nl. First CK was 206 with second pending.\nRESP: Pt sating 90-94% on 5L NP. She has rales up 1/2 bilaterally. She has received lasix 40mg and is diuressing.\nRENAL: Creat .9. She has foley and was initially hematuric, but with lasix urine has cleared.\nGI: Apetite poor tonight. She had some custard and takes pills without problem.\nMS: Pt is very pleasant, cooperative and communicative, but has poor short term memory. She has posey vest on as she may well try to get OOB in the night and needs to be watched. She walks with walker at home and always has family member with her. Her husband died 4 year ago and her father many years ago, but she frequently talks as if they were alive.\nA: S/P stent\nP: Continue to re-orient pt and keep her in bed. Monitor for ectopy. Check results of labs. Check groin. D/C integrelin at 6am.\n" } ]

[ { "category": "Radiology", "chartdate": "2150-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989832, "text": " 6:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for aspiration pneumonia\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p TAAA stent with trach\n REASON FOR THIS EXAMINATION:\n eval for aspiration pneumonia\n ______________________________________________________________________________\n WET READ: 9:55 PM\n Increase left lung base opacity may represent the combination of pleural\n effusion and atelectasis. Cannot rule out pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Status post TAAA stent. Question aspiration.\n\n Compared to the prior study, there has been a slight increase in the opacity\n at the left lung base likely representing a combination of pleural effusion\n and atelectasis or infiltrate. Underlying aspiration cannot be excluded.\n Tracheostomy tube remains in adequate position, 3.7 cm above the carina. There\n is a left-sided PICC line, the tip of which is at the junction of the SVC and\n right atrium. Right lung is clear. Aortic stent is noted, the appearance of\n which is unchanged.\n\n IMPRESSION: Increased opacity at the left lung base, likely a combination of\n increased pleural effusion and associated atelectasis or infiltrate. Findings\n would be consistent with aspiration. Clinical correlation is advised.\n\n jr\n\n\n" }, { "category": "Radiology", "chartdate": "2150-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989885, "text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p TAAA repair with stent\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:30 A.M :\n\n HISTORY: Aortic repair. Evaluate for pleural effusion.\n\n IMPRESSION: AP chest compared to through 6:\n\n Small to moderate left pleural effusion continues to increase. New\n consolidation in the right lower lobe is concerning for pneumonia particularly\n aspiration. Cardiomediastinal silhouette is unchanged. Left lower lobe\n atelectasis is worsened. Tracheostomy tube in standard placement. Tip of the\n right PIC catheter projects over the low SVC. No pneumothorax. \n was paged to report these findings at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990819, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p TAAA stent\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old female status post thoracic AAA stent, evaluate for\n pleural effusions.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST, ONE VIEW: Status post aortic stent placement. Tip of\n right central venous catheter is in mid to upper SVC. Tracheostomy tube is\n unchanged in position. Gastrostomy tube superimposed over the left upper\n quadrant abdomen.\n\n Interval improvement of right lower lobe consolidation and left retrocardiac\n opacity and pleural effusion. There continues to be a small ill-defined\n retrocardiac density, likely representing atelectatic changes as well as a\n small left pleural effusion. Cardiomediastinal silhouette is stable.\n\n IMPRESSION:\n\n 1. Interval improvement of right lower lobe consolidation.\n\n 2. Interval improvement of left pleural effusion, now small.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989451, "text": " 4:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check dophoff placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p endovascular AAA repair\n REASON FOR THIS EXAMINATION:\n check dophoff placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endovascular AAA repair, to check Dobbhoff placement.\n\n FINDINGS: In comparison with the study of , there is no change in the\n appearance of the graft and the heart and lungs. Right central catheter again\n extends to the mid portion of the SVC.\n\n Dobbhoff tube has been placed with its tip in the distal stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990077, "text": " 11:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? dobhoff placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with s/p thorocabdominal stent\n REASON FOR THIS EXAMINATION:\n ? dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n Status post aortic stent graft. Comparison to the\n preexisting pleural effusion left is distributed in a slightly different way\n but has not notably increased in size. The retrocardiac atelectasis is little\n more extensive than on the previous radiograph. The other findings are\n unchanged.\n\n IMPRESSION: Slightly different distribution, but unchanged extent of the\n left-sided pleural effusion after aortic stent grafting, slight increase of\n the retrocardiac atelectasis.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2150-11-25 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 989590, "text": " 1:45 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: dysphagia\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p TAAA stent\n REASON FOR THIS EXAMINATION:\n dysphagia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 58-year-old woman status post thoracic AAA stent,\n evaluate for dysphagia.\n\n COMPARISON: None.\n\n VIDEO OROPHARYNGEAL SWALLOW EVALUATION: Oral and pharyngeal swallowing\n fluoroscopy was performed in collaboration with the speech and swallow team.\n Multiple barium consistencies were administered. There is mild delay in\n pharyngeal swallowing with premature spillover and mild tongue weakness.\n Administration of thin liquids caused penetration with clearance after\n swallowing. There was no aspiration.\n\n IMPRESSION: Mild weakness and swallow delay with thin liquids causing\n penetration without evidence of aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2150-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990837, "text": " 11:25 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval PICC placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p TAAA repair\n REASON FOR THIS EXAMINATION:\n eval PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC placement. Thoracic aortic stent graft.\n\n COMPARISON: at 10:10.\n\n UPRIGHT AP CHEST: The right PICC has been retracted a short distance, with\n tip now overlying the superior portion of the SVC. Retrocardiac opacity has\n slightly increased in the interim, likely increased atelectasis. Otherwise,\n there is no significant interval change since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-11-21 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 988948, "text": " 1:55 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: s/p thorocoabd stent, r/o endo leak\n Admitting Diagnosis: HYPOTENSION\n Field of view: 39 Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman endovascular stent\n REASON FOR THIS EXAMINATION:\n s/p thorocoabd stent, r/o endo leak\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT OF THE CHEST, ABDOMEN AND PELVIS.\n\n INDICATION: 58-year-old female status post thoracoabdominal aortic stent.\n Assess for a leak.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast MDCT axial images of the chest, abdomen, and pelvis\n were acquired. Following the administration of 60 mL of Optiray intravenous\n contrast, MDCT axial images were acquired from the thoracic inlet to the pubic\n symphysis. Coronal and sagittal reconstructed images were then obtained.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: The patient is status post\n endotracheal intubation. The patient is status post endovascular stenting of\n the thoracic aorta beginning at the level of the aortic arch and extending\n inferiorly to the level of T12 approximately. A focal area of contrast\n extravasation is noted anteriorly along the graft at the junction of the two\n overlapping grafts and measures 3.1 x 0.8 cm (series 401B:image 39).\n Comparison to the previous CT examination demonstrates increased of the size\n in this focal leak. Once again, surrounding hematoma is noted concentrically\n around the graft and not appreciably changed in size compared to the previous\n evaluation. There is moderate-to-severe cardiomegaly. No pericardial\n effusion is present. The pulmonary artery is enlarged, measuring 3.5 cm.\n There is bibasilar dependent atelectasis. The lungs are otherwise grossly\n clear. The patient is status post median sternotomy. Few mediastinal lymph\n nodes are noted, none of which meet criteria for pathology by CT.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Once again, note is made of multiple\n hyperattenuating nodules throughout the liver. Several low-attenuation foci\n are consistent in appearance with simple cysts. The liver is grossly\n unchanged compared to the previous evaluation. A moderate-sized left pleural\n effusion is noted. The kidneys, adrenal glands, spleen, pancreas, gallbladder\n and abdominal portions of the large and small bowel appear grossly\n unremarkable and unchanged compared to the previous examination. There is no\n free fluid within the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: A Foley balloon is present within the\n collapsed bladder. The rectum, sigmoid colon, uterus and adnexa appear\n unremarkable. There are no pathologically enlarged inguinal or pelvic lymph\n (Over)\n\n 1:55 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: s/p thorocoabd stent, r/o endo leak\n Admitting Diagnosis: HYPOTENSION\n Field of view: 39 Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n nodes. No free fluid is present within the pelvis.\n\n OSSEOUS STRUCTURES: There is severe S-shaped scoliosis of the thoracolumbar\n spine. T12 and L2 compression fractures are unchanged.\n\n IMPRESSION:\n\n 1. Findings consistent with an endoleak at the level of the graft- to-graft\n anastomosis in the mid thoracic cavity anteriorly. This focal area of\n contrast extravasation has increased compared to the CT of .\n Relatively stable appearance of peri-aortic hematoma.\n\n 2. Left moderate subpulmonic effusion.\n\n These findings were discussed over the telephone with by Dr.\n at approximately 3:00 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2150-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989137, "text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, at 16:36 HOURS.\n\n COMPARISON STUDY: \n\n CLINICAL INFORMATION: Question infiltrate.\n\n FINDINGS:\n\n Tracheostomy is in the midline. Thoracic aortic stent graft is unchanged.\n Right PICC terminates in the superior vena cava. Again noted are several rib\n deformities on the left. There is mild left retrocardiac opacification, which\n could attest to either consolidation or atelectasis. There is a small left\n pleural effusion. These findings have developed since the prior study. The\n right lung is clear.\n\n IMPRESSION:\n\n New left retrocardiac opacity, atelectasis versus consolidation. New small\n left pleural effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-11-24 00:00:00.000", "description": "Report", "row_id": 1471324, "text": "NEURO: Pt A&Ox2. Becomes very anxious and agitated, RR^, HR ^& SBP^. Can talk pt down, however she becomes very forgetful. Pt c/o min pain on buttocks ? if from rash, relief with repositioning. Pt seems very depressed, ? antidepressant. Pt states she \"feels she is dying.\" Pt has 1:1 sitter.\n\nCV: PT in NSR, 70s-90s. 20mg IV Q6 ordered. Added 20mg to 50cc NS and ran over 30mins, by pt. Nicardipine gtt off this am. SBP ^160s at times, when pt calm and comfortable SBP 120s. Pt given PRN 10mg Hydralazine for SBP >150. Pt also ordered for enalaprilat 1.25mg IV Q6H. Pt to cath lab for angiogram to check for ? leaking grafts. No leak noted, pt not given sedation for procedure, given 100cc contrast. 4Fr sheath removed R femoral, angio site warm, soft, CD&I. PP palpable. Heparin gtt to be restarted @ 2230. Hct stable, PLT ^.\n\nRESP: Pt cont on trach mask 35%. Sats high 90s. LS clear upper lobes, diminshed in the bases. Pt suctioned for scant secretions. Passy-muir speaking valve on.\n\nGI/GU: Pt diuresising well. + BS heard. ? Placement of new dobhauff this shift. Pt will have swallow eval in the am.\n\nENDO: Individual sliding scale, BS tx prn.\n\nSKIN: afebrile. Rash on buttocks, using nystatin cream. ? med reaction. Vanco level drawn this am, 21.7 dose held this am, NP aware give dose.\n\nPLAN: Continue to monitor neuro, resp, HR, SBP <150, u/o, angio site. Restart heparin gtt @ 2230. Vanco due @ . Swallow eval tomorrow.\nBedrest until . Cont NS @ 50/hr\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-11-23 00:00:00.000", "description": "Report", "row_id": 1471320, "text": "Ekvents: OR cancelled until tomorrow. 1:1 sitter. INR 2.3, vit K 5mg SQ.\n\nNeuro: Alert, oriented to self, talking about \"missing my flight\", reorients with much reminding. Follows commands, mae.\n\nCV: Sr/no ectopy, nicardapine gtt weaned/dc'd. Metoprolol q4hr with PRN hydralzine to keep sbp</= 120.\n\nPulm: Trach collar with 35%02. Lungs clear bilaterally. Expectorates small amounts thick white sputum. She is able to talk in short sentences. 02 sat 100%.\n\nGU: Uo clear yellow draining to gravity at >30cc/hr\n\nGI: Remains npo, asking for food, no NG access. Bs present, no stool this shift.\n\nSkin: Surfaces grossly , pulses present. Mild red rash on buttocks, crititcaid anti fungal protective ointment applied.\n\nSoc: Son in to visit, updated on pt condition/poc by Dr. .\n\nP: Reorient/reassure prn, continue 1:1 sitter. Follow vitals signs, notifty team of unresolved hypertension >120. For speech/swallow eval as above, for angio in OR tomorrow, keep npo. Pm coags, ?heparin gtt if INR <2.\n" }, { "category": "Nursing/other", "chartdate": "2150-11-23 00:00:00.000", "description": "Report", "row_id": 1471321, "text": "Respiratory Care:\nPt did not go to the OR today for stenting (cardiac). She remains on\nTrach mask @ 35% and has recieved MDI's with Combivent x 3. Sx'd as needed and changed IC x 2 today.\n" }, { "category": "Nursing/other", "chartdate": "2150-11-24 00:00:00.000", "description": "Report", "row_id": 1471322, "text": "resp care\nPt given 6puffs combivent mdi/spacer as ordered. BS bil.#7portex trach/cuff down. Suct for sml amts of thick tan sput.Will cont to follw with mdi /suct.\n" }, { "category": "Nursing/other", "chartdate": "2150-11-24 00:00:00.000", "description": "Report", "row_id": 1471323, "text": "cv:SBp 130's to 140 despite lopressor iv atc and hydalzine 10 mg iv prn.. notified and nicardipine restarted with good r esponse. nicrdipine off briefly during night but sbp up to 154 this a.m. and nicardipine restarted.. hr 68-83 nsr no ectopy.\n\ngi: pt c/o hunger. requesting food. pt reminded about her npo status. pt c/o nausea because she is not eating so zofran 4 mg iv given.abdomen soft, positive bowel sounds.\n\ngu: foley draining clear yellow urine at least 40 cc/hr.\n\nresp: o2 via trach mask .35 % sats 97-100 %.\n\nmental status: pt oriented to slef and did report the year as . pt does not retain the info that you give her and will ask the same question shortly after you have already answered.MAE to command.\n\naccess: r antecubital.\n\nheparin turned off at 0630 in prep for ? OR today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-11-22 00:00:00.000", "description": "Report", "row_id": 1471317, "text": "NEURO ALERT NODS APPROPRIATLY MOUTHING WORDS WITH SOME VERBALIZATION AROUND TRACH. MOVES ALL EXTREMETIES BECOMES AGITATED EASILY CALMS WITH REASSURANCE. ATTEMPTS OOB AND PULLING AT LINES WHEN NOT SUPERVISED. CALMS AND APPROPRIATE WITH SUPERVISION./SITTER.\n\nC/V NSR NICARDIPINE FOR B/P CONTROL 1.5MCGS WELL. PULSES PALP EXTREMETIES WARM AND DRY. MAINTAINING B/P < 120 SYSTOLIC.\n\nRESP MAINTAINING ON TRACH MASK SATS 99% LUNGS COARSE IN ALL LOBES AT TIMES IMPROVES WITH SUCTIONING. TRACH CARE DONE ABLE TO CLEAR SECRETIONS BECOMES ANXIOUS AT TIMES. STATES \" I NEED TO CLEAR THE MUCOUS\" CALM WITH SUCTIONING MINIMAL AMTS.\n\nGU/GI ABD SOFT HYPOACTIVE BOWEL SOUNDS NPO MINIMAL URINE OUT 15-20 CC HOUR FOLEY IRRIGATED WITH POOR RETURN FOLEY CHANGED WITH NO IMPROVEMENT IN OUTPUT. DISCUSSED WITH DR ,\n\nPLAN CONTINUE TO MONITOR RESP STATUS MONITOR URINE OUTPUT MAINTAIN SAFETY WITH SITTER DURING AGITATION.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-11-23 00:00:00.000", "description": "Report", "row_id": 1471318, "text": "Resp: Pt rec'd on 35% humidified t/c. Pt has #7 portex trach with cuff deflated. BS are coarse to clear and able to expectorate secretions. Coughing up thick tan to bloody tinged secretions. MDI's administered via trach of combivent with no adverse reactions. OR procedure today (stent).\n" }, { "category": "Nursing/other", "chartdate": "2150-11-21 00:00:00.000", "description": "Report", "row_id": 1471312, "text": "Respiratory Care;\nPt seen x 3 for MDI Rx's with a spacer, she has required suctioning\nvia trach x mult for moderate amounts of loose clear to white secretions. Changed Trach IC x 2 today...\n" }, { "category": "Nursing/other", "chartdate": "2150-11-21 00:00:00.000", "description": "Report", "row_id": 1471313, "text": "Shift note 0700-2300\n\nFALL RISK\n\nROS:\n\nNeuro: Alert oriented x's . Confused to time and place most constently oriented to self. MAE x's 4 to command. Cooperative yet forgetfull. Figity in bed. Repositions self for comfort. Denies pain. . Verbalizes around trach to.\n\nCV: RSR w/o ectopy. VSS w/metoprolol and hydralazine IV. BP to be 120's or less per vascular team. Peripheral pulses palpable. No edema.\n\nResp: . On trach mask 35% FIO2 mainly for humidification. Sats 97-100% even on room air. Breath sounds clear and diminished. Sx sm to mod amt of thin to thick clear/white. No resp distress noted, = rise and fall of chest.\n\nGI: NPO. Abd soft w/active BS. Small soft stool Heme (-).\n\nGU: Foley patent draining clear yellow urine in QS.\n\nEndo: FSG covered w/SSI\n\nLabs: non checked this shift.\n\nSocial: Daughter phoned. Son in to visit. Supportive.\n\nPlan: BP mngt goal for SBP 120's or less. Pulmonary toilet. Mobilize. FALL PRECAUTIONS. Monitor, tx, support, and comfort. To have further eval of leaking vessel in via angiogram in OR maybe on Monday or sooner if condition warrents. Change po protonix to IV.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-11-22 00:00:00.000", "description": "Report", "row_id": 1471314, "text": "CVICU NPN 2300-0700\nNEURO: ALERT, ORIENTED X (PERSON/PLACE) AT TIMES. AT 0200, PT BEGAN SCREAMING AROUND TRACH, THRASHING IN BED. GIVEN HALDOL IV AS ORDERED AND DOCUMENTED WITH RELIEF. COARSE TREMORS IN BLE. 1:1 SITTER FOR SAFETY OF LINES/TRACH.\n\nCV: MP SR, NO ECTOPY. STARTED ON NICARDIPINE FOR HTN (SBP > 150) - SBP IN 110S AT THIS TIME.\n\nRESP: , ON HUMID TRACH COLLAR. EXPECTORATED AND SXN VIA TRACH FOR THICK SPUTUM THAT WAS BRIGHT RED IN COLOR, NO BLOODY. ? ASPIRATION OF JELLO. L/S RHONCHEROUS WITH DIM BASES. NP.\n\nGI/GU: ABD BENIGN. FOLEY PATENT W/ADEQUATE HUO.\n\nENDO: SSRI.\n\nPLAN: ? OR ON MONDAY FOR ANGIOGRAPHY. ASPIRATION PRECAUTIONS. CONTINUE WITH NICARDIPINE FOR B/P MANAGEMENT. EMOTIONAL SUPPORT. ? ADDING HALDOL TO REGIME AS PT WAS ON IT DURING LAST ADMIT.\n" }, { "category": "Nursing/other", "chartdate": "2150-11-22 00:00:00.000", "description": "Report", "row_id": 1471315, "text": "Resp: Pt rec'd on 35% t/c with humidification. BS are coarse to clear and pt has strong cough. Some bloody secretions expectorated, possibly due to aggressive suctioning during day. MDI's administered via trach of combivent with no adverse reactions. Pt has #7 portex trach with cuff deflated. No resp distress noted. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2150-11-22 00:00:00.000", "description": "Report", "row_id": 1471316, "text": "Respiratory Care:\nPt. seen for MDI's via trach with a spacer. Sx'd as necessary and IC changed x 2. Had some dry secretions removed and increased the humidity to moisten sec.\n" }, { "category": "Nursing/other", "chartdate": "2150-11-23 00:00:00.000", "description": "Report", "row_id": 1471319, "text": "NEURO: ALERT, MOUTHING AND SPEAKING APPROPRIATE WORDS, SENTENCES. FOLLOWS COMMANDS, MAE. COARSE TREMORS OF UPPER EXTREMITES. HOLLERS OUT \"HELP ME..HELP ME\" WITH EPISODES OF COUGHING. RESPONDS TO POSITIVE REINFORCEMENT.\n\nPULM: 35% TRACH COLLAR, SATS > 98%. STRONG COUGH, USUALLY ABLE TO COUGH OUT SECRETIONS THROUGH TRACH BUT NEEDS FREQUENT EMOTIONAL SUPPORT D/T PANIC OF \"CAN'T BREATHE.\" SX'D FOR THICK DK BROWN MUCUS PLUG X 2. LUNGS DIMINISHED IN BASES AFTER SXING.\n\nCV: NSR WITH PAC'S, BRIEF BURST OF SVT ~ 0630 WITH AGITATION. NICARDIPINE GTT DECREASED TO 1.0MCG FOR CONSISTENT MAP < 60. PEDAL PULSES PRESENT. 5MG VITAMIN K AT 2230 FOR INR 2.9, REPEAT INR 2.3 THIS AM.\n\nENDO: QID SSRI COVERAGE. NO INSULIN THIS SHIFT. BS 72 AT 0400.\n\nGI: ABDOMEN SOFT, + BS. C/O SHARP PAIN LLQ EARLY IN SHIFT BUT RESOLVED WITHOUT RX. NO NUTRITION IN 3 DAYS. PT REPEATEDLY ASKING FOR SOMETHING TO DRINK AND EAT. \"I'M STARVING.\"\n\nGU: FOLEY TO CD DRAINING QS AMTS CLEAR YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRES.\n\nPLAN: EMOTIONAL SUPPORT. SX VIA TRACH ONLY IF NOT ABLE TO CLEAR ON HER OWN D/T HIGH INR AND INCREASED BLEEDING WITH REPEATED SX'ING. NEEDS SOME NUTRITION, ? TPN VERSUS DOBHOFF. HOB ELEAVTED TO PREVENT ASPIRATION. ? ENDOVASCULAR STENT PLACEMENT FOR ? LEAKING GRAFT SITE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-11-21 00:00:00.000", "description": "Report", "row_id": 1471311, "text": "NEURO: pt admitted from outside hospital calm, cooperative oriented to person only. through night with periods of agitation and anxiety, states sees husband in corner of room. , . generalized weakness more pronounced on L than R. pt with coarse tremor of UE's. denies pain but states R wrist is tender to touch. examined by orders. slight foot drop, MP boots applied.\nRESP: pt on trach collar 35% fio2 resps even and unlabored when at rest suctioned for scant tan secretions, not enough to culture. lungs diminished bilat. bases. sats 96-100%.\nCV: sinus rhythm-sinus tach 80's-100's. APc's and PVC's resolved with lyte repletion. pulses L arm difficult to palpate, cuff pressure followed L thigh. HTN repsonsive to metop 5 mg IV and hydral. 10 mg IV. compression stockings on. CT chest/abd/pelvis done. HCT stable x2.\nGI/GU: abd soft distended +bowel sounds. NPO. no BM this shift. foley with cloudy/sludgy yellow urine. sent for C&S\nSKIN: abdominal incision with steristrips CDI, no dressing. groin/buttocks with yeast/moisture rash. skin care done with barrier cream nystatin ordered.\nID: vanco random sent. urine cultured. needs sputum cx when able. aztreonam given x1 dose, awaiting ID approval.\npsych/soc: no calls this shift. pt states lives with son.\nA/P: hemodynamically and resp stable. awaiting results of CT scan. will need anticoag for AVR. ?transfer to medicine. sputum cx when able. continue trach/skin care. Needs nutrition eval.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-07-01 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1146460, "text": " 11:14 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: 50 year old woman with aneurysmal SAH s/p coiling. Please ev\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with aneurysmal SAH s/p coiling. Please evaluate for\n vasospasm.\n REASON FOR THIS EXAMINATION:\n 50 year old woman with aneurysmal SAH s/p coiling. Please evaluate for\n vasospasm.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw WED 3:49 PM\n No acute intracranial hemorrhage or mass effect.\n Patent major vessels, similar to prior to CTA. pending 3d reformations.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aneurysmal SAH, from posterior communicating artery, status post\n coiling, to evaluate for vasospasm.\n\n COMPARISON: CT head done on , CTA head done on .\n\n TECHNIQUE: Non-contrast CT head, followed by CT angiogram of the head was\n performed. 2D and 3D reformations were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT HEAD: Again visualized is a small hypodense area in the left\n parietal lobe at the vertex series 2, image 28, felt to represent a small area\n of acute infarction, not new since and not significantly changed, since\n studies.\n There is no new acute intracranial hemorrhage or mass effect. The ventricles\n and the extra-axial CSF spaces are unremarkable. Evaluation of the structures\n at the level of the circle of , is limited due to the artifacts from the\n coiled aneurysm. No osseous lytic or sclerotic lesions are noted. The\n visualized portions of the paranasal sinuses reveal mucosal thickening in the\n sphenoid sinus. The visualized soft tissues of the scalp are unremarkable.\n\n CT ANGIOGRAM OF THE HEAD:\n\n Evaluation of the coiled aneurysm is limited due to artifacts. Similarly,\n there is some limitation of the vessels adjacent to the coiled aneurysm. There\n is no gross change in the caliber of the anterior and the middle cerebral\n arteries. However, there are 2 short segments of narrowing of the P2 segment\n of the posterior cerebral artery on the left side, series 3, image 62,63, new\n from prior. However, there is no flow limitation distally.\n Atherosclerotic vascular calcifications and non-calcified plaques are noted in\n the cavernous carotid segments on both sides, with some degree of stenosis\n without flow limitation. Mild narrowing in the distal Basilar artery may be\n artifactual, from the beam hardening artifacts on correlation with the axial\n source images.\n (Over)\n\n 11:14 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: 50 year old woman with aneurysmal SAH s/p coiling. Please ev\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. No significant change in the hypodense area in the left parietal lobe at\n the vertex compared to the recent study of , though it is new compared to\n and may represent a focus of infarction.\n\n 2. Short segment areas of stenosis, in the left posterior cerebral artery -\n P2 segment, may be real/related to adjacent artifacts from the coils. Short\n segment narrowing of the distal Basilar artery is likely related o artifacts.\n Atherosclerotic calcified and non-calcified plaques in the cavernous segments\n on both sides with some degree of stenosis.\n Otherwise, no flow-limiting stenosis or occlusion of the major arteries noted.\n Evaluation of the coiled aneurysm is limited on the present study.\n\n 3. Mild mucosal thickening in the sphenoid sinus.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-23 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1145166, "text": " 12:00 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: eval for aneurysm, known SAH\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49F trx from OSH with SAH, ?aneurysm\n REASON FOR THIS EXAMINATION:\n eval for aneurysm, known SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd TUE 1:36 AM\n extensive SAH centered at the left aspect of the suprasellar cistern.\n 7mm x 7 mm lobulated aneurysm at the junction of the left MCA and carotid\n artery.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Female with outside hospital examination demonstrating subarachnoid\n hemorrhage, to assess for the extent and also exclude an aneurysm.\n\n TECHNIQUE: Multidetector CT of the brain was performed without intravenous\n contrast followed by CTA of the head and neck post-administration of\n intravenous contrast.\n\n There is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n There is extensive high density filling the suprasellar as well as the other\n subarachnoid spaces consistent with extensive acute subarachnoid hemorrhage.\n The midline structures are central. There is no evidence to suggest\n hydrocephalus at the current time. The ventricles appear unremarkable. There\n is no bony abnormality.\n\n CT ANGIOGRAM:\n\n There is dependent atelectasis present in both lungs. There are up to 8 mm in\n short axis mediastinal lymph nodes.\n\n There is minimal atherosclerosis present at the carotid bifurcation. The\n common carotid, internal and external carotid arteries are widely patent in\n their cervical course.\n\n Minimal atherosclerosis is present in the cavernous internal carotid artery\n bilaterally.\n\n There is a 6.9 x 6.9 mm supraclinoid aneurysm arising from the left internal\n carotid artery which has a lobulated, irregular appearance and also\n demonstrates a neck at the junction of the left internal carotid artery with\n the MCA and PCA (image 243, series 3). The remaining branches of the left\n internal carotid artery are widely patent. The intracranial branches of the\n right internal carotid artery, vertebral arteries, basilar artery and its\n branches are widely patent. The right internal carotid artery measures 3.6 mm\n (Over)\n\n 12:00 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: eval for aneurysm, known SAH\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in transverse diameter its dital course, the left internal carotid artery\n measures 3.3 mm in transverse diameter its dital course\n\n There are minor degenerative changes present throughout the cervical spine.\n There is no bony abnormality otherwise seen.\n\n IMPRESSION:\n\n 1. 6.9 x 6.9 mm lobulated, irregular aneurysm arising from the supraclinoid\n left internal carotid artery as described above.\n\n 2. Acute subarachnoid hemorrhage.\n\n The images were reviewed and findings were discussed with Dr. by\n Dr. at 11 a.m. on .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-06-23 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 1145249, "text": " 11:21 AM\n CAROT/CEREB Clip # \n Reason: 49 year old woman with SAH, r/o aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 277\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with SAH, r/o aneurysm\n REASON FOR THIS EXAMINATION:\n 49 year old woman with SAH, r/o aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n EDICAL HISTORY: This is a 49-year-old woman who presented with thunderclap\n headache, found to have subarachnoid hemorrhage with left posterior\n communicating aneurysm. Her CT scan showed subarachnoid hemorrhage centered in\n the left suprasellar cistern with 7 x 5 mm lobulated aneurysm at the origin of\n posterior communicating artery.\n\n PROCEDURE: Cerebral angiogram with right common carotid arteriogram, left\n vertebral arteriogram, left common carotid and left internal carotid\n arteriograms with coil embolization of the left posterior communicating\n aneurysm using seven of GDC-10 Soft and UltraSoft coils and closure of the\n right common femoral using 6 French Angio-Seal closure device.\n (Over)\n\n 11:21 AM\n CAROT/CEREB Clip # \n Reason: 49 year old woman with SAH, r/o aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 277\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OPERATOR: Dr. .\n\n ASSISTANT: Dr. and Dr. .\n\n SEDATION: The procedure was done under general anesthesia.\n\n DETAILS OF THE PROCEDURE: Written informed consent was obtained from the\n patient after explaining indications, risks, benefits and alternative\n management of the procedure. Risks included but not limited to damage to the\n blood vessels, risk of stroke or aneurysm rupture causing temporary or\n permanent neurological deficits or death. The consent was obtained in the\n presence of the patient's daughter and mother \"her healthcare proxy.\" All\n agreed to proceed with the procedure. The patient was brought into the\n neurointerventional suite and placed in supine position on biplane table.\n Anesthesia was induced and patient was intubated. Then, both groins were\n prepped and draped in standard sterile fashion. A preprocedural huddle\n followed by timeout documenting patient identity, nature of the procedure,\n relevant blood workup, investigation and the equipment that will be used\n during the procedure was done using two independent verifiers. Then, after\n using local anesthetic into the right groin, access was gained to the right\n common femoral artery using a micropuncture set. Using Seldinger technique, a\n 6 French vascular sheath was successfully placed into the right common femoral\n artery and connected to continuous drip of heparin and saline mixture. Through\n the sheath, using 2 catheter with the aid of 0.038 angled glidewire\n that was connected to continuous pressurized drip of heparin and saline\n mixture over the sidearm of contrast injector, the right common carotid artery\n was selectively catheterized first and AP, lateral and oblique arteriograms\n were obtained. Then, the left vertebral artery was selectively catheterized\n under road-map guidance and AP and lateral arteriograms obtained with hand\n injection. Then, the left common carotid was selectively catheterized and\n three-dimensional arteriogram was obtained. Then, under road-map guidance,\n with the aid of exchange-length Glidewire, the catheter was removed\n and exchanged for 6 French straight Neuron catheter and placed into the distal\n cervical portion of the left internal carotid artery. Then, after reviewing\n the images and selecting the best working projection that showed the aneurysm\n with the parent vessels, we used the SL-10 microcatheter with a Synchro\n standard microwire to successfully and safely catheterize the aneurysm. Then,\n using GDC-10 360 Soft 5 x 9 coil as a frame, we started coil embolization of\n the aneurysm. This was followed by using another two GDC-10 360 Soft coils of\n 4 x 8 cm and one GDC-10 360 Soft coil 3 x 6 cm. An arteriogram was obtained\n during coil embolization which showed patent branch vessels and the coils\n nicely packed inside the aneurysm. Then we continued the coiling using GDC-10\n UltraSoft coils of 2.5 x 6 and 2.5 x 4 and 2 x 4 cm lengths. Total of seven\n GDC-10 coils were used. During coil embolization, the patient received a\n (Over)\n\n 11:21 AM\n CAROT/CEREB Clip # \n Reason: 49 year old woman with SAH, r/o aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 277\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n total of 6000 units of heparin to keep the ACT more or equal to 250. Post\n coil embolization runs showed minimal opacification of the neck with patent\n parent vessels. At the end of the procedure, catheters and wire were removed.\n A right common femoral arteriogram was done, which showed wide patent vessels.\n The site of the puncture was closed using 6 French Angio-Seal closure device.\n The sedation was lightened and patient was extubated. Her neurological\n examination after the procedure was nonfocal. She was sent to the ICU with\n post-procedure orders. Our findings and interventions were discussed with the\n ICU team and neurosurgery team and the patient's family.\n\n FINDINGS:\n Right common carotid arteriogram showed normal filling of the internal carotid\n on cervical, petrous, cavernous and supraclinoid portions. Both middle and\n anterior cerebral arteries were seen and appeared normal. There was a\n prominent posterior communicating artery. The external carotid artery with\n its branches were seen and appeared normal.\n\n Left vertebral arteriogram showed normal filling of the left vertebral artery\n with codominant vertebrals and normal reflux of contrast into the\n contralateral side. Basilar artery appears normal in course and caliber. Both\n PCAs and SCAs were seen and appeared to be originating from single trunk.\n No aneurysm noted.\n\n Left common carotid arteriogram showed normal filling of the internal carotid\n along the cervical, petrous, cavernous, and supraclinoid portions. There was\n multilobulated aneurysm at the origin of the posterior communicating artery\n projecting posteriorly and measures 7 x 4.8 mm with a narrow neck and single\n trunk at the Origin of both the aneurysm and the posterior communicating\n arteries where it arises superomedial to the aneurysm neck. Both middle and\n anterior cerebral arteries were seen and appeared normal. The aneurysm was\n successfully coiled using seven GDC-10 coils. Post coil embolization showed\n minimum opacification of the neck of the aneurysm with patent parent vessels.\n\n Right common femoral arteriogram showed wide patent vessels at the site of\n punctures above the bifurcation though there is no evidence of extravasation\n or dissection.\n\n IMPRESSION: Diagnostic cerebral angiogram showed the presence of left\n posterior communicating aneurysm that measures 7 mm x 4.8 at the origin of the\n posterior communicating artery projected posteriorly. This aneurysm was\n successfully coiled as above.\n\n\n\n (Over)\n\n 11:21 AM\n CAROT/CEREB Clip # \n Reason: 49 year old woman with SAH, r/o aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 277\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2161-06-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1145780, "text": " 4:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval change.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with SAH s/p coiling.\n REASON FOR THIS EXAMINATION:\n Eval for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: s/p aneurysm clipping\n\n COMPARISON: \n\n TECHNIQUE: A non contrast CT of the head was performed.\n\n FINDINGS: The patient is status post coiling of a left posterior communicating\n artery aneurysm. Streak artifact limits visualization of the skull base.\n There is a small amount of residual subarachnoid hemorrhage identified, most\n prominent at the convexities bilaterally. Also noted is a new hypodattenuating\n area in the left anterior parietal lobe which is suspicious for an area of\n acute infarction. The remainder of the grey white matter differentiation is\n preserved, There is no intraparenchymal hemorrhage or shift of midline\n structures. The ventricles are normal in appearance. The calvarium is intact.\n The paranasal sinuses are clear. Electrodes are noted along the scalp.\n\n IMPRESSION:\n\n 1. New area of hypoattenuation in the left parietal lobe s/p aneurysm\n coiling, suspicious for acute infarction.\n\n 2. Small amount of residual subarachnoid hemorrhage.\n\n These findings were communicated to Dr. on at 5pm.\n\n" }, { "category": "ECG", "chartdate": "2161-06-25 00:00:00.000", "description": "Report", "row_id": 191287, "text": "Sinus rhythm. Possible inferior myocardial infarction. Anterior precordial\nT wave changes are suggestive of ischemia. Compared to the previous tracing\nof no change.\n\n" }, { "category": "ECG", "chartdate": "2161-06-22 00:00:00.000", "description": "Report", "row_id": 191288, "text": "Sinus rhythm. Non-diagnostic small Q waves in the inferior leads.\nCompared to the previous tracing of there is no significant diagnostic\nchange.\n\n" } ]

[ { "category": "ECG", "chartdate": "2186-11-04 00:00:00.000", "description": "Report", "row_id": 248744, "text": "Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-04-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 788744, "text": " 3:16 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tube removal-r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal-r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post chest tube removal.\n\n COMMENT: PA and lateral chest xrays are reviewed, and compared with previous\n study of .\n\n The patient is status post CABG and mediansternotomy. There is elevation of\n the left hemidiaphragm with atelectasis in the left lower lobe. Tiny\n pneumothorax is seen in the left apical region. The right lung appears clear.\n Heart is normal in size. No evidence of congestive heart failure. There is\n small bilateral effusion.\n\n IMPRESSION: A tiny left apical pneumothorax. 2. Status post CABG and median-\n sternotomy. 3. Elevation of the left hemidiaphragm with atelectasis in the\n left lower lobe. 4. Small bilateral effusion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 788344, "text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with IABP and GNR bacteremia\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intra-aortic balloon pump and gram negative rod bacteremia. Assess\n for pneumonia.\n\n COMPARISON: None.\n\n FINDINGS: Single supine chest radiograph demonstrates an intra-aortic balloon\n pump with tip approximately 1.5 cm below the aortic arch. The cardiac and\n mediastinal contours are normal. There is no pulmonary vascular congestion,\n pleural effusion, focal infiltrate, or pneumothorax. The bones and soft\n tissues are unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "Echo", "chartdate": "2164-04-23 00:00:00.000", "description": "Report", "row_id": 74990, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment. Patient on IABP.\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 117/70\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 15:21\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve is not well seen. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. No mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Image quality was suboptimal.\n\nConclusions:\nLimited study. Pt on IABP. The left atrium is normal in size. Left ventricular\nwall thicknesses are normal. The left ventricular cavity size is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). The number of\naortic valve leaflets cannot be determined. The aortic valve is not well seen.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2164-04-21 00:00:00.000", "description": "Report", "row_id": 74595, "text": "PATIENT/TEST INFORMATION:\nIndication: 70y/o man with angina, LMCA disease for CABG. WMA and LVEF.\nHeight: (in) 66\nWeight (lb): 160\nBSA (m2): 1.82 m2\nBP (mm Hg): 121/53\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 13:34\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. Trivial mitral regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nVery limited study. The left atrium is mildly dilated. There is mild symmetric\nleft ventricular hypertrophy. The left ventricular cavity size is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\nno pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2164-04-24 00:00:00.000", "description": "Report", "row_id": 169689, "text": "Sinus rhythm. Diffuse ST-T wave changes with ST segment elevation - suggest in\npart early repolarization pattern but consider also possible\npericarditis/injury. Prominent precordial QRS voltage - suggest left\nventricular hypertrophy. Clinical correlation is suggested. Since the previous\ntracing of further ST-T wave changes are present.\n\n" }, { "category": "ECG", "chartdate": "2164-04-22 00:00:00.000", "description": "Report", "row_id": 169690, "text": "Sinus rhythm\nNonspecific ST-T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2164-04-22 00:00:00.000", "description": "Report", "row_id": 169691, "text": "Sinus rhythm\nNonspecific ST-T abnormalities\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2164-04-20 00:00:00.000", "description": "Report", "row_id": 169692, "text": "Sinus rhythm\nNonspecific anterior T wave changes\n\n" }, { "category": "Nursing/other", "chartdate": "2164-04-21 00:00:00.000", "description": "Report", "row_id": 1447205, "text": "Nursing Progress Note, Addendum.\n\nCV: Pt had a diff night c two episodes of acute cardiac distress. The first episode occurred @ 22:00 @ which time a 20 gauge PIV was placed into the pt RUE. Unfortunately, the pt vagalled c his HR dropping to the 30's c a reduction in SBP to the 70's. One amp of Atropine was provided IVP, HO notified, EKG obtained and a 500ml NS bolus was provided. Pt HR recovered rather quickly(<3 minutes), but his hypotension persisted for approx 30 min. Pt denied CP c this incidense but did report feeling lightheaded. The pts second episode occurred @ 04:00 when the pt called for assistance c his call bell and reported CP. Pt med c a total of 2# tabs SL Nitroglycerin and 2mg IV MSO4. HO called, EKG obtained (significant ischemic changes), CP resolved within 5 minutes. The pt VS initailly were WNL during this CP episode, however his BP dropped again to the 70's following the admin of MSO4 and SL Nitro. HO contact CT Surgery to discuss the pts, will cont to medically manage this pt c unstable angina. Pt angiocath remains in place (R fem artery), pt requires freq reminders to keep RLE straight (knee emobilizer placed, unfortunately the pt removed this device). Pt cont to have good palpable p.tibialis pulses. Afebrile this AM (Tmax of 99.9 during eve shift).\n\nLABS: AM CPK value = 311. K and Mg repleted PO and IV respectively O/N -- AM K and Mg values WNL. Heparin gtt currently infusing @ 900units/hr via L UE 20#gauge PIV c therapeutic PTT of 64.3 this AM. Other AM labs WNL.\n\nGI: NPO for CABG today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-04-21 00:00:00.000", "description": "Report", "row_id": 1447206, "text": "nursing note 7a-7p\nNEURO-A/A/O X 3,MAE,no c/o pain.cooperative with nursing care.pt.anxiouse at times c ^sbp.\n\nRESP-n/c at 2l,no c/o sob,rr-10's,no cough,bs-clear.\n\nCV-echo done this am,sb-57-sr-60's,no ectopy,no c/o cp,started on nitro gtt this am at 0.05mcg/kg/min -titrate to cp & sbp-100-130.,now at 0.18mcg/kg/min,sbp-120-150's,r-fem angiocath-intact-rle kept straight all times, all pulses palpable.heparin gtt at 750u/hr next ptt at 1800.ct surgery did eval this pm,cabg-pnd .\n\nGI-NPO,abd soft,bs+,no bm,no c/o nausea.\n\nGU-voiding,urine cl & yellow.\n\nSKIN-intact\n\nSOCIAL-family at bedside up-dated per ccu team.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-22 00:00:00.000", "description": "Report", "row_id": 1447207, "text": "NPN\nMICU\n7 PM - 7 AM\nUNSTABLE ANGINA >> PRE-OP CABG\nEPISODE OF CP AT 1900 ..CHANGE OF SHIFT ..WITH PT C/O OF SLIGHT CP AND EKG WITH SIGNIFICANT ST DEPRESSIONS ACROSS HIS PRECORDIUM...IV NTRO INCREASED TO 200 MCGS ...EKG WITH RESOLUTION OF CHANGES BACK TO BASELINE BY ....PTT THERAPEUTIC ON 750 U/HR ..PT VERY ANXIOUS GIVEN .5 OF IV ATIVAN TIMES 2 ..AND PT FOUND OUT OF BED ..CONFUSED AND DISORIENTED ..DR AWARE AND IN TO SEE PT ....ATTEMPTING TO SELF D/C FEM ALINE ..PERIPHERAL IVS...WRISTS RESTRAINED ..ABD BINDER APPLIED ...GIVEN A TOTAL OF 6 MG OF IV HALDOL WITH GOOD AFFECT ...SLEEPING REST OF NIGHT ...NEURO CLEARING TO BASELINE BY 0500....LOPRESSOR INCREASED TO 50 MG ... CT AND DR AWARE OF RECURRENT CP WITH CHANGES ..\nRESP ON 3L NP WITH CLEAR LUNGS\nGI NPO\nGU FOLEY INSERTED WITH IMMEDIATE RETURN OF 800 CC UPON INSERTION ..SUBSEQUENT U/O 60-80 CC Q2\nA UNSTABLE ANGINA WITH ISCHEMIC CHANGES\nP ? IAB INSERTION IF CP RETURNS ..NEEDS ANTI-ANXIETY MED ( SERAX ) ..PREOP CABG ..\n\n" }, { "category": "Nursing/other", "chartdate": "2164-04-23 00:00:00.000", "description": "Report", "row_id": 1447211, "text": "CCU NPN 1100-2300\nS/O: SEE CAREVUE FOR OBJECTIVE DATA.\n\nCV: IABP CONT 1:1 WITH GOOD AUMENTING AND UNLOADING. LEFT GROIN SITE WITHOUT HEMATOMA OR BLEEDING. PULSES STRONG, FEET WARM. LOPRESSOR/CAPTOPTIL CONT. HEP AT 800U/HR, PTT>150 SO HEP OFF FOR 1 HOUR AND .5 CC. PT/INR NL. K 3.3 SO 60 MEQ GIVEN PO X1 AND 40 MEQ WRITTEN TO GIVE IN AM. NTG CONT TO KEEP SBP <130. PRE-OP SCRUB DONE. CLOT SENT TO BB. PRE-OP TEACHING DONE AND REVIEWED. PT IS FIRST CASE TOMORROW.\n\nRESP: SATS IN HIGH 90'S ON 2LNP. LUNGS CLEAR. LASIX 40 MG GIVEN IV X1\n\nID: AWAITING FURTHER CX RESULTS. AFEB, WBC NL.\n\nGI: FAIR APPETITE, NPO AFTER MN.\n\nGU: USING URINAL, URINE CLEAR.\n\nMS: PLEASANT AND COOPERATIVE, SEEMS TO HAVE A GOOD UNDERSTANDING OF SURGERY AND MEDS. WIFE AND DAUGHTERS IN TO VISIT, ALL QUESTIONS ANSWERED. DENTURES AND GLASSES AT BEDSIDE.\n\nA/P: CHECK PTT AGAIN AT AM LABS. FOLLOW VS ON NTG. NPO AFTER MN. FOLLOW DIURESIS. MONITOR IABP GROIN SITE.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-24 00:00:00.000", "description": "Report", "row_id": 1447212, "text": "CCU Nursing Progress Note 2300-0700:Left main DZ\nS-\"No.No questions.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND VS\n\nMS:A/O/X/3. Very pleasant and cooperative. Initially complaining of insomnia but later falling off to sleep. Reluctant to give sleep aid due to psychosis and hallucinations to benzos this admission. Obeys and follow commands appropriately. MAE. Denies questions in regards to surgery.\n\nCV: HR 60s. NSR with no noted ectopy. IABP 1:1 with good augmentation and little unloading. MAPs 80s. Nitro off on prior shift due to vagal episode. Denying CP throughout shift. Left groin site CDI, no hematoma or ooze noted at site. Pulses palpable distal with good palor and warm. Heparin continues at 450u/hr with AM PTT pending.\n\nRESP:LSCTA. 99% on 4LNP. Denies SOB. No issues.\n\nGU/GI: Voiding CYU in urinal without difficulty. NPO after MN. (+) BSs.\n\nID: Tm 98.8. No issues\n\nA/P: 70 year old male who presented to OSH with unstable angina and found to have 3VD, including left main, on cath. On transfered to for CTSURG c/s. ICU course complicated by frequent episode of CP later requiring IABP for afterload reduction.\n\nCABG this AM\n\n" }, { "category": "Nursing/other", "chartdate": "2164-04-24 00:00:00.000", "description": "Report", "row_id": 1447213, "text": "CCU Nursing Progress Note Addedum:\nNitro restarted for MAPs on IABP high 90. Nitro restarted at 1.0mcg/kg/min.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-04-20 00:00:00.000", "description": "Report", "row_id": 1447204, "text": "Nursing Transfer Note.\n\nThis is a pleasant 70 yr old male admitted to today () electively for a CABG procedure to be performed during this admit. The pt is in NAD, MAE and is pleasant/cooperative. NKDA. Full Code. Good family support noted c wife and two dtrs @ BS. The pt had been admitted to Hosp on monday c a history of recent stable angina for w/u. Pt found to have significant multi-vessel dz c elevated CPK values (but flat MB/troponin levels). Pt PMH includes; HTN (poorly cntl?). BPH?. Stable angina(new). S/P cholecystectomy. Poor peripheral access. Borderline elevated cholesterol. +Remote smoker (quit 25 years ago). +Family history of cardiac dz.\n\nCV: HDSA. Heparin gtt in place infusing @ 800units/hr (increased to 900units/hr @ 22:00 c a 21:00 PTT = 45.9). Pt denies CP/palpitations. NSR c no ectopy. Repeat labs drawn/sent @ 21:00 c blood clot to BB for routine type/cross. Cont to cycle CPK's per team request. Atropine @ BS c report of sinus bradycardia (30's)(c a reduction in BP) assoc c back pain earlier today which responded to 1 amp Atropine.\n\nRESP: LSCTA. 2LNCO2 in place. No SOB/dyspnea.\n\nACCESS: The pt has an 18 gauge PIV in his L UE AC and a large bore R Femoral sheath/A-Line in place. Pt c easily palpatable posterior tibialis pulses but weak dorsalis pedal pulses. LE are symmetrical, no edema evident.\n\nGU: Voiding c urinal. Urine is a clear yellow.\n\nFAMILY: Wife and dtr visited this evening and kept abreast of POC/pt status.\n\nOTHER: Please see CareVue for additional pt care data/comments. Currently awaiting HO order sets/transfer orders.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-22 00:00:00.000", "description": "Report", "row_id": 1447208, "text": "NSG PROG/TRANSFER NOTE\n***SEE ALSO NSG TRANSFER NOTE*****\n\n70y.o. man admitted w/ L main disease, transfer from OSH, awaiting IABP placement today with CABG Tues. Stable on NTG, HEPARIN, BETA BLOCKER, CAPTOPRIL.\n\nNKDA\n\nROS:\n\nCARDIAC: Last CP 1900(approx 30min) w/ ant/lat ischemic changes that resolved when pain free. Precipitated by anxitey. Titrating ntg for b/p 110-120/sys. hr 67 nsr no vea.\n\nRESP: clear to aus. 2Lnc w/ sats 96-98%. No sob.\n\nGI: NPO since yesterday.\n\nRENAL: bun/cr wnl. Decreased u.o. this am w/ b/p 90's, increased when b/p 110-120/sys.\n\nNEURO: He had paradoxical response to ativan last eve, creating tremendous agitation and psychosis. Tx successfully w/ haldol. Resting comfortably, sleeping most of day, oriented with appropriate conversation.\n\nSKIN: intact\n\nLINES: R fem art line placed Friday. No signs of infection, weak palp DP to bil feet, good palp pulses PT bil. Feet warm to touch.\n\nID: t 100.1 po today- sent bl cx from art line.\n\nSOCIAL; dtr is med student, lives w/ wife. Family aware of plans for pt.\n\nASSESS: stable, awaiting IABP today and CABG on Tues.\n\nPLAN; follow ptt, hourly u.o., keep anxiety managed w/ haldol\n" }, { "category": "Nursing/other", "chartdate": "2164-04-23 00:00:00.000", "description": "Report", "row_id": 1447209, "text": "CSRU ADM/UPDATE\nNEURO: AAOX3. PLEASANT AND COOPERATIVE TO CARE.\n\nCV: RECEIVED FROM CATH LAB S/P IABP INSERTION IN LT FEM. RT FEM ART LINE D/C BY CARDIOLOGY UPON ARRIVAL. RT FEM SITE C&D. IABP SITE ALSO C&D. VS AS PER FLOWSHEET. IABP W/ GOOD SYS UNLOADING, MIN TO NO DIASTOLIC UNLOADING.ON NTG , TITRATED FOR BP. HEPARIN RESTART AT 0420 AT 800U/HR. FEET WARM W/ PERIPH PULSES EASILY PALPED.\n\nRESP: LUNGS CLEAR. O2 SATS HIGH 90'S ON 2L N/C.\n\nGI: ABD SOFT. NPO EXCEPT FOR SIPS W/ MEDS.\n\nGU: UOP QS VIA FOLEY.\n\nID: T 99.5 PO. +BC REPORTED FOR GM NEG RODS.\n\nASSESS: STABLE POST PROCEDURE. PAINFREE.\n\nPLAN: CONT TO MONITOR. TREAT BC. ? DATE FOR CABG.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-04-23 00:00:00.000", "description": "Report", "row_id": 1447210, "text": "PT UPDATE\n PT IS A&O X3. VERY CALM AT THIS TIME. BS CLEAR WITH SATS 98 ON 2LNP. PT ON .2 MCG/KG/MIN NTG AND 800U HEPARIN. PT IN SR WITH IABP 1:1 WITH ONLY FAIR UNLOADING DURING NIGHT; SOMEWHAT IMPROVED THIS AM. PT IS CURRENTLY . BP STABLE. URINE C&S SENT THIS AM 0800 AND FOLEY D/C'D AS ORDERED. PT REMAINS NPO. AS REPORTED; PT HAD BC DRAWN LAST NIGHT. AFEB THIS AM. 2 REPEAT PERIPH BC SENT THIS AM AND PT STARTED ON CIPRO AS ORDERED; AND TO BE STARTED ON GENTA. ?PT TO GO TO SURGERY TOMORROW. PT'S DAUGHTER CALLED THIS AM AND GIVEN UPDATE RE: PT . PT NOW TO BE TRANSFERRED TO CCU.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-24 00:00:00.000", "description": "Report", "row_id": 1447214, "text": "ADMIT NOTE\nPT TO CSRU 1255 POST-CABG X 3 INTUBATED AND SEDATED ON PROPOFOL W/LEVOPHED IV GTT RUNNING. IABP 1:1.\n\nCV: LEVOPHED OFF W/IN 15 MIN FOR SBP IN 140'S, LOW DOSE IV NTG STARTED TO KEEP MAP IN 60-90 RANGE. C.I. CONSISTENTLY 2.5 OR GREATER. CT W/ MIN SANG DRNG. 2A AND 2V EPICARDIAL WIRES TESTED-BOTH SENSE AND CAPTURE; PLACED ON AAI @ 60 FOR BACKUP. W/ PALP PULSES BILAT.\n\nNEURO: PT REVERSED AND PROPOFOL OFF. PT IS CALM. NODS HEAD, MAE AND FOLLOWS COMMANDS. STILL SLEEPY HOWEVER. DENIES PAIN AFTER MSO4 GIVEN.\n\nRESP: LUNGS CLEAR. SPO2=100% ON FIO2 .50. ALTHOUGH VT'S GD, RR ONLY 6 WHEN VENT WEAN ATTEMPTED SO KEPT ON IMV 6 FOR NOW.\n\nG.I.: SM AMT OF DK BILIOUS DRNG VIA OGT.\n\nG.U.: LG DIURESIS AFTER ARRIVAL. K+ BEING REPLACED.\n\nSKIN: INTACT, DRSGS DRY.\n\nENDO: INSULIN GTT STARTED FOR GLUC IN 150'S.\n\nA/P: HEMODYNAMICALLY STABLE BUT SLEEPY. WILL CONT VENT WEAN AS TOL. NEURO INTACT. VISITING W/ FAMILY THIS AFTERNOON. PAIN MED PRN. INSULIN/GLUCOSE PER PROTOCOL. PER DR. , WEAN IABP LATER TONIGHT IF STABLE FOR D/C IN A.M.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-24 00:00:00.000", "description": "Report", "row_id": 1447215, "text": "resp status\nPT EXTUBATED TO 4L NC O2 @ 1830. SPO2 98%. VOICE HOARSE BUT AUDIBLE. C/O DRY THROAT. MOUTH SWABS GIVEN.\nPLAN: MONITOR SPO2, RR AND ENC C&DB. PAIN MED PRN.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-24 00:00:00.000", "description": "Report", "row_id": 1447216, "text": "PROB: S/P CABG X3\n\nCV: IABP 1:2 WITH GOOD AUGMENTATION, PULSES GOOD, FEET WARM. SR-ST WITH OCC PAC NOTED. CT DRAINING S/S DRAINAGE. MED FOR PAIN WITH MORPHINE WITH FAIR EFFECT.\n\nRESP: LUNGS CLEAR. C/DB WITH ENCOURAGEMENT. O2 SATS 98%.\n\nGU: CLEAR YEELOW URINE, OUTPUT ADEQUATE.\n\nGI: BOWEL SOUNDS ABSENT.\n\nENDO: INSULIN DRIP TITRATED TO BS, PRESENTLY AT 2U/HR FOR BS OF 111.\n\nNEURO: ALERT AND ORIENTED X3. MAE. RESTLESS AT TIMES.\n\nASSESSMENT: TOLERATING IABP AT 1:2.\n\nPLAN: CONT.\nWEAN IABP\nCULTURE IF TEMP SPIKE.\nPAIN MED PRN\n" }, { "category": "Nursing/other", "chartdate": "2164-04-25 00:00:00.000", "description": "Report", "row_id": 1447217, "text": "SHIFT UPDATE:\n\nNEURO: A&O X3. MAE. TURNING S->S IN BED INDEPENDANTLY. DENIES PAIN.\n\nCARDIAC: SR-ST. HR 90-100'S. OCCAS->RARE PVC NOTED. BRIEF RUN OF SVT HR >170. SELF LIMITED. DR AWARE. TO START ON PO LOPRESSOR THIS AM. IABP CONT AT 1:2->GOOD AUGMENTATION. CI>2.5. ?D/C IABP THIS AM. CT'S MINIMAL. +PP BILATERALLY.\n\nRESP: LUNGS CLEAR. SAT'S>97%. CDB W/ENCOURAGEMENT.\n\nGI/GU: +BS. TOLERATING ICE CHIPS & SIPS OF H2O. UOP BORDERLINE LASIX 20MG IV GIVEN.\n\nENDO: CONT ON INSULIN GTT. SEE FLOW SHEET.\n\nPLAN: ?WEAN & D/C IABP. MONITOR HEMODYNAMICS. PULMONARY TOILET. INSULIN GTT. MONITOR EFFECT OF LASIX. PAIN MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-25 00:00:00.000", "description": "Report", "row_id": 1447218, "text": "NPN:\n\nNeuro: Alert and oriented X3, MAE equally.Follows commands. Conversing appropriately.\nCV: 90-100 NSR with rare APC and rare PVC. Started on Lopressor 12.5 mg - no further SVT. IABP dc'd 1030am with CI> 2.2. PA pressures stable-Swan dc'd. K and Mg repleted. Palp pedal pulses-with warm and dry skin.\nResp: Lungs sl diminished at bases otherwise CTA. O2 sats>98% on 3l nc-weaned to 2l. CT/MT to sxn- no airleak-draining sm amts serosang.\nGI: Tol clears -Abd soft, NT,ND, + BS. No N/V. Will feed this PM when OOB.\nGU: Foley to gd with good initial diuresis after IV lasix at 630am. Cr stable.\nEndo: Insulin gtt weaned off and pt treated with ss insulin.\nIncisions: Chest and MT with dsd-D/I. R leg with ace wra[ intact-D/I.\nComfort: Denies pain Med X1 witrh Perc with relief.\nActivity: Turned side to side in bed with min assist. On bedrest until 1630pm- Pt very anxious to get OOB.\nA: Stable with IABP dc'd and no gtts.\nP: OOB to ch this eve.- Cont lopressor-replete lytes prn. Assess for CT dng-possibly dc after OOB. Possible transfer to 2 in am.\n" }, { "category": "Nursing/other", "chartdate": "2164-04-26 00:00:00.000", "description": "Report", "row_id": 1447219, "text": "NEURO-COMPLETELY INTACT. VERY RIGID WITH CARE.\n\nCV-NSR 85 NO ECTOPY. BP STABLE BY CUFF.PALPABLE PULSES X4. EXTREMITIES WARM/DRY.\n\nRESP- 2LNC=97%. LSC,DIM AT BASES.\n\nG.I.-ABD SOFT + BS. NO P.O LIQUIDS DURING THE NOC.\n\nG.U.-BORDERLINE U/O X 2 HRS. WILL ADDRESS WITH TEAM DURING AM ROUNDS.\n\nINC. C-D-I-.\n\nLABS- STILL PENDING.\n\nPLAN-DC CORDIS,OOB TO CHAIR.TRANSFER TO 2 THIS AM.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2180-04-12 00:00:00.000", "description": "Report", "row_id": 1575864, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. HAS CONTINUED TO SPIKE TEMPS FOR PAST SEVERAL DAYS. MRCP YESTERDAY SHOWED DILATED BILE DUCTS WHICH NEED COMPRESSION. PROBABLE CHOLECYSTITIS. PT. TO HAVE ERCP TODAY. HAS BEEN NPO SINCE MIDNIGHT. PT. ALSO TO HAVE PICC PLACED THIS AM AS R IJ IS SEVEN DAYS OLD AND NEEDS TO BE REMOVED.\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. PUPILS EQUAL AND REACTIVE. NO C/O PAIN THIS SHIFT. HE REMAINS VERY FRUSTRATED AND CONTINUES TO REFUSE O2 AND SOME NSG. CARE.\n\nRESP: PT. REMAINED ON R/A AS HE REFUSES TO WEAR O2. SATS HIGH 80'S TO LOW 90'S. BREATH SOUNDS FREQUENTLY WITH EXPIRATORY WHEEZES WHICH CLEAR WITH PRN NEBS. DIMINISHED IN BASES. DYSPNEA NOTED WITH ANY TYPE OF EXERTION. PT. WITH NON PRODUCTIVE COUGH.\n\nCV: NSR/ST. NO ECTOPY NOTED. SBP HIGH 80'S TO LOW 100'S. MAP >60. + PULSES. NO EDEMA. TMAX 101.7 AXILLARY. GIVEN TYLENOL 650MG Q4 WITH LITTLE EFFECT.\n\nGI: PT. ON BRAT DIET, HOWEVER, HAS BEEN NPO SINCE MIDNIGHT FOR ERCP TODAY. ABD. SOFT. BS DISTANT. PT. DID HAVE SMALL LOOSE BM THIS SHIFT. GUIAC NEGATIVE\n\nGU: PT. VOIDING IN URINAL AND INCONTINENT OF URINE IN LARGE AMOUNTS AT TIMES. OUTPUT INACCURATE. PT. ENCOURAGED TO ALLOW CONDOM CATH, HOWEVER, CONTINUOUSLY REFUSING. MD'S AWARE\n\nSKIN: INTACT\n\nACCESS: R IJ TL\n\nPLAN: ERCP TODAY. TYPE AND CROSS DRAWN AT MIDNIGHT AND SENT TO BLOOD BANK FOR PROCEDURE. PICC TO BE PLACED THIS AM AS WELL. CONTINUE WITH CURRENT ANTIBIOTIC THERAPY. MONITOR RESP/HEMODYNAMIC STATUS CLOSELY. AM LABS PENDING. PT. IS DNR. NO CONTACT WITH FAMILY THIS SHIFT.\n\nSKIN: INTACT\n" }, { "category": "Nursing/other", "chartdate": "2180-04-12 00:00:00.000", "description": "Report", "row_id": 1575865, "text": "NPN 0700-1900\nNeuro: A&OX3, grips equal &\"4\", legs equal & \"4\". No trembling,nausea, tactile disturbances, hallucinations etc.(CIWA scale) Unaware of time periods, ie when waiting 5min, thinks its 30 min.\n\nCV: HR 80's-90's SR no ectopy. Repleted slowly w/60 mEq KCL for serum K3.4. No repletion for Mg 1.9 per Dr. . BP 80's-100's/systolic. Will treat for sBP<80/ per rounds. IonizedCa= 1.12(WNL). Recieved 1 unit PLT's for PLT CT 32,000, to bring it up to 51,000. Recieved 2 units FFP as well pre ERCP to prevent bleeding (INR was 1.6 this am).\n\nResp: O2 sat 89-99% on room air. Refused to wear O2. SOB w/ speaking & activity. RR19-35. Head of bed raised 30-45 degrees for comfort w/ breathing. Can lie flat for turning for short periods of time. Patient had diffuse wheezes this am, recieved albuterol & atrovent neb Tx's w/clearing of lung fields to: wheeze @ R base & crackles @ L base (upper lungs clear). Recieved robitussin w/codeine X1.\n\nID: Temps 93.7-94.9po/ax. BP& HR stable. Increased temp in room. Covered patient w/blankets. Bair hugger set up in room but patient refuses it.\n\n\nGI: Having frequent watery brown w/small lumps, guiac negative stools: X5 in 5 hrs. Stool sent for O&P, C-diff. So far, C-diff negative. + bowel sounds. Firm,distended abdomen. Has ascites. LFT's elevated. For ERCP today to decompress bile ducts.\n\nGU: Voiding in 150-200cc amounts clear yellow urine. Refused foley catheter. Team aware. Swelling @ foreskin &penis &scrotum. Condom catheter not suggested because of swelling @ this time.\n\nSkin: Skin slightly reddened around rectum. Area cleaned well & barrier cream applied. Skin intact otherwise. PICC to be placed in R arm on by IV nurse @ bedside. Will need CXR to confirm placement (of PICC) & then will need another CXR to confirm that PICC did not move after R IJ pulled.\n\nCoping: Anxious & depressed. Recieved 0.5mg po ativan per patient request q 4 hrs. Member of his church called about coming to visit him. He verbalized desire to change his health care proxy from his sister to his minister.\n\nActivity: Remained on bedrest. Urge to void or defecate comes on too quickly to use commode. Can turn himself in bed.\n\nA/P: Patient is SOB from COPD, abd pushing against lungs, not using O2--limit activity to what patient tolerates, give neb Tx's q 6 hrs as needed, encourage O2 if sats worsen.\n Frequent watery stool-- await final C-diff Cx results, clean skin q BM, use barrier cream, BRAT diet post ERCP\n Anxiety-- offer emotional support.\n Low temp--check temp frequently. Keep temp up in room. Keep patient covered.\n Send patient to ERCP when they are ready for him.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-12 00:00:00.000", "description": "Report", "row_id": 1575866, "text": "Addendum to NPN 1800\nMr. went down for his ERCP @ 1630 & returned @ 1730. He was intubated for the procedure & extubated just before he came back to MICU. No gag reflex @ the time of this note prevents anything po @ this time. Procuctive cough noted frequently w/ sticky clear secretions. O2sat on 3L NP93-96%. Temp 95po-HR 91SR no ectopy -RR 20 cuff BP 104/24. Recieved 2mg versed & 100mcg fentanyl,& propofol during procedure. Sleeping-but easily arousable & oriented X3. No stones nor need for stent.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-12 00:00:00.000", "description": "Report", "row_id": 1575867, "text": "PLT's not given before ERCP as they were not available until after the patient went down. The GI MD's & anesthesiology decided not to give PLT's before the ERCP based on the 1330p PLT CT 51,000.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-13 00:00:00.000", "description": "Report", "row_id": 1575868, "text": "MICU progress note 7p-12a\nUneventful evening.\npositive gag - able to start back on clear fluid - advance diet as tolerated.\ngiven ativan 0.5mg po at midnite for anxiety, and neb tx for SOB/wheezes. LS scant crackles L bases, I/E wheezes on exertion. O2 3L overnite post ERCP.\nTemp 95.\nSBP 90-100s. SR 90s. no ectopy.\nvoids in urinal. no loose stool tonite.\n\nPLAN: ?call out tomorrow. ?bone marrow biopsy in am. Due for PICC line placement and RIJ TLC to be d/c'd and cultured. remains on contact precautions until cdiff ruled out.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-13 00:00:00.000", "description": "Report", "row_id": 1575869, "text": "resp care\nPt given alb/atro neb as ordered. BS diffuse bil wheeze. RR labored.Cough prod of sml amts of thick white sput. Will cont to follow with nebs.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-13 00:00:00.000", "description": "Report", "row_id": 1575870, "text": "Respiratory Care: pt seen for atrovent/albuterol nebs. Lungs sounds expiratory wheezes specially with exertion. Tolerated txs well. will follow.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-07 00:00:00.000", "description": "Report", "row_id": 1575847, "text": " nursing note 06.00-07.00\nNeuro:\npt alert and orientated x3 .Pt denies pain .\n\nCV:\nSee carevue for objective data,pt was given 5lt fluid in the ed ,then placed on septic protocol as bp not responding,commenced on levophed @ 0.05mcg/kg/hr.Tmax 101.8 in the ed ,now 99.7 .2 sets of blood cultures sent.\n\nGI/GU:\npt having d/v x 5 days,one episode of watery stool since admission .\npt had 1,750 output in the ed,using bottle to void .Stool and urine sent to lab.\n\nResp:\nLung sounds clear in all lobes,rr rate increased due to temp ,on 02 3l via nasal cannuala.For sv02 monitoring .\n\nSkin:\nOn contact precautions due to loose stool and vomiting.\nIV access x2,wnl also pt has rt triple lumen ij wnl.\n\nSocial:\nNo family with pt.\n\nPlan :\nMonitor cvp,bp ,svo2 and follow up and replete lytes.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-07 00:00:00.000", "description": "Report", "row_id": 1575848, "text": "NPN 0700-1900\n\nNeuro: A&O X3, tired from lack of sleep past few days. Able to sleep in naps. Given ativan 1mg po X1 for c/o anxiety with good effect. MAE's, says he is very weak from not eating in days.\n\nCV: Levophed weaned off by 0730; NBP 87-143/55-77, given total 2500cc NS fluid bolus for low BP and CVP <12; HR 85-130, SR/ST with rare PVC, less tachy in afternoon when Temp down and after fluid boluses; CVP 8-12; no peripheral edema. Repeat crit this am 28.8\n\nResp: O2 sat 97-100% on O2 at 3L NC; RR 24-35, pt reports breathing feels better today than past couple of days; Lung sounds are clear upper lobes, diminished lower lobes with intermittent scattered wheezes. Frequent productive cough of white sputum in am, but this has subsided. RT to start alb/atr nebs and to get induced sputum for r/o PCP.\n\nGI/FEN: NPO for U/S of g/b and liver (results pending); was tolerating clear liquids prior; says he feels hungry and wants to eat; abdomen is firmly distended with +BS; had watery stools throughout the day, specimen sent this am, will need daily specs for C.diff. Lytes repleted as follows: 40meq KCL IV for K of 3.5, 4gms Ca gluconate for Ca of 1.03\n\nGU: Voiding ~100cc concentrated urine at a time; fluid balance is +6500cc; received total of 2500cc NS IVF boluses.\n\nID: Tmax 104 at 0900 -> cooling blanket on and given tylenol 650mg; Tcurrrent 99; on vanco, levo, flagyl. Most recent lactate 1.0;\n\nPlan: Monitor temp, wbc's, follow cultures, antibiotics as ordered, obtain sputum and stool specs as ordered; albuterol nebs q 6hrs, O2 @ 2-4L NC to maintain O2 sats >92%; monitor fluid/electrolyte status, replete prn; goal CVP >12 -> NS fluid bolus 500cc prn; pt is dnr/dni.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-10 00:00:00.000", "description": "Report", "row_id": 1575858, "text": "MICU/SICU NPN ICU day #4\nEvents: transfused 2U PRBC, spiked to 101.6PO, bolused with 1 L LR for hypotension, pt became acutely SOB with diffuse wheezes after pivoting to commode\n\nS: \"Why is my breathing so bad? I'm so anxious, what's wrong?\"\n\nO:\n\nNeruo: pt is A&Ox3, MAEW, denies pain, transfers bed to commode with supervision, extremely anxious\n\nPulm: LS are mostly CTA, but pt became acutely SOB after transfer to commode and developed diffuse expiratory wheezes requiring albuterol/Atrovent/lidocaine neb, resp status improved over several hours\n\nCV: HR 100-127 ST without appreciable ectopy, BP 76-155/39-87, CVP 15, please see flowsheet for data\n\nInteg: C/W/D/I\n\nGI/GU: abd soft, NT/ND, BS present, tolertating BRAT diet without difficulty, pt continues to have soft loose stool, voiding small amts amber urine in urinal and commode\n\nAccess: right IJ PreSept cath day #4, PIV x2\n\nA:\n\nanxiety r/t hospitalization/diagonsis\nhigh risk for infection r/t invasive line\nfluid volume deficit r/t GI losses\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue abx as ordered and follow micro data, continue BRAT diet, activity progression as tolerated, aggressive pulmonary toilet\n" }, { "category": "Nursing/other", "chartdate": "2180-04-10 00:00:00.000", "description": "Report", "row_id": 1575859, "text": "MICU EAST NPN 0700-1900\naddendum. Plan to start Meropenum. Awaiting ID approval.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-15 00:00:00.000", "description": "Report", "row_id": 1575875, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. WAS CALLED OUT TO FLOOR YESTERDAY, HOWEVER, HE BECAME TACHYCARDIC AT START OF SHIFT AND REMAINED HERE IN UNIT OVERNIGHT FOR CLOSE OBSERVATION. PT. STATED HE WAS FEELING ANXIOUS, WHICH IN TURN \"MADE MY BREATHING BAD\" HE WAS GIVEN PRN NEBS AND ATIVAN PRN THROUGHOUT SHIFT AND APPEARS VERY COMFORTABLE AT THIS TIME.\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. PUPILS EQUAL AND REACTIVE. HE IS VERY DISCOURAGED WITH HIS ILLNESS STATING AT TIMES THAT HE WOULD LIKE TO GO HOME. CONTINUES TO REFUSE OXYGEN AND PNEUMO BOOTS. NO C/O PAIN THIS SHIFT. ATIVAN PRN FOR ANXIETY.\n\nRESP: PT. ON AND OFF 3L NASAL CANNULA WITH SATS REMAINING >97%. BREATH SOUNDS WITH EXPIRATORY WHEEZES WHICH CLEAR WITH NEBS. COARSE THROUGHOUT. PT. WITH PRODUCTIVE COUGH\n\nCV: NSR/ST. NO ECTOPY NOTED. SBP WNL. + PULSES. GENERALIZED EDEMA NOTED. PM K+ 3.4 TREATED WITH 40MEQ KCL IV AT START OF SHIFT. AM LABS PENDING. TMAX 100.0. MEDICATED WITH TYLENOL WITH GOOD RESULT.\n\nGI: PT. ON REGULAR DIET BUT WITH LITTLE APPETITE. STARTED ON TPN YESTERDAY. ABD. SOFT. BS+. SMALL BM THIS SHIFT.\n\nGU: PT. REFUSING FOLEY. CONTINUES TO BE INCONTINENT OF URINE. I'S AND O'S INNACCURATE AT THIS TIME.\n\nSKIN: INTACT\n\nACCESS: L AC DL PICC PLACED YESTERDAY\n\nPLAN: CONTINUE WITH CURRENT POC. MONITOR RESP. STATUS CLOSELY. MEDICATE WITH ATIVAN PRN FOR ANXIETY. ? C/O TO FLOOR IF PT. STABLE THIS AM. PT. DNR/DNI. NO CONTACT WITH FRIENDS/FAMILY THIS SHIFT.\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-15 00:00:00.000", "description": "Report", "row_id": 1575876, "text": "resp care\nPt given alb/atro neb as ordered. Bs coarse bil wheeze. Cough prod of thick white sput.Pt has periods of tachypnea which decreaes somewhat with the neb. Intermittently wearing a 3l can. Will cont to follow with nebs.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-10 00:00:00.000", "description": "Report", "row_id": 1575860, "text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details..\n\nA&O. Using commode w/assist. Says he is anxious, wants to sleep and be left alone. Given .5mg Ativan x1. Refusing O2 and O2sats on RA 89-92.\n\nLung sds with intermittent exp wheezes. Given nebs by RT and stated he felt much better with return to clear lung sds. Plan for induced sputum for PCP by RT.\n\nFreq bouts of diarrhea this am which increased after eating (PO intake very ). Stool OB- and spec sent. Have improved sl this afternoon.\n\nPlat. Ct stable at 46. Hct also stable at 27. HIT antibody sent. R IJ with mod amt of bleeding ? r/t getting in and out of bed frequently. Re-dressed with surgifoam. No bleeding noted at present. Paln for PICC when fevers subsided.\n\nContinues to spike temps daily. Cefepime dc'd. Remains on Vanco, flagyl and Levo.\n\nNo episodes of hypotention.\n\nFollowed by Social service. Stated his mother, now , was his HCP. would like his sister to be his HCP but he hasn't spoken to her about it.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-10 00:00:00.000", "description": "Report", "row_id": 1575861, "text": "RESPIRATORY CARE: PT GIVEN TX X 1 FOR COUGH/ WHEEZE.\nALBUTEROL/ATROVENT/XYLOCAINE COCKTAIL. SUB/OBJ RX TO TX.\nPT REFUSED SPUTUM INDUCTION ATTEMPT TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-15 00:00:00.000", "description": "Report", "row_id": 1575877, "text": "7A-7PM Nsg Progress Note\nID: pt spike temp 100.9 PO, blood cx's x 2 drawn (one set from PICC LINE, one set peripheral), urine cx sent. 650 mg tylenol given po. pt on Vanco and Meropenem. to CT scan for Head, Chest, Abd/pelvic.\npt drank barocat. negative for PE, pt with new ascites, and pleural effusions. need trough Vanco level in am.\n\nRESP: on 3 l n/p rr~22-30 dyspneic on exertion, doesn't tolerate lying flat. pt with exp wheezing after CT scan - received .5 mg po Ativan, and an Albuterol/atrovent neb. wheezing decreased.\n\nCV: remains tachycardic (pt febrile) HR 110-120 ST no vea noted,\nBP stable ~ 120/70\n\nGI: belly firm, distended. passed liquid stool x2. on regular diet, appetite, TPN continues at 42 cc/hr. on Protonix.\n\nGU: able to use urinal with assistance. inc of stool I~1866 UO~ 830 (approx) with loose stool.\n\nNEURO: pt A+Ox3, very weak, needs assistance to turn and lift legs in bed. cooperative.\n\nIV ACCESS: left antecubital PICC line, dsg changed, working well, site clean and no signs of redness.\n\nSKIN: intact.\n\nPLAN: check cultures, continue antibx, monitor resp status. follow fever curve. enc po intake. PT consult. ?call out in am.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-18 00:00:00.000", "description": "Report", "row_id": 1575888, "text": "Note:\nPt was called out of ICU and he had a bed in 711 ( 7, ), report given to RN and ambulance was called. When the ambulance arrived in patient's room, pt changed his mind of being transferred from ICU to another unit and insisted to go home. HO informed and the resident MD talked in length with the patient who still insisted to go home. Nursing supervisor ( ) and the ICU resource nurse informed, then security was called and thereafter a code purple was made and a psychiatric consultant talked to pt. Prior to that, pt was given 2 mg Haldol IV, which calmed him down. After the psych. consultant spoke to pt, he verbalized that he will stay in the hospital. Resident MD informed and 7 RN informed that pt is to be transferred to 7.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-13 00:00:00.000", "description": "Report", "row_id": 1575871, "text": "RESP: PT. EXPERIENCING RESP DISTRESS WITH ANY EXERTION. BECOMES WHEEZY, REQUIRING A TREATMENT. CONT. TO REFUSE TO WEAR HIS O2. C&R THICK WHITE SECRETIONS. GIVEN COUGH SYRUP X1.\nGI: TAKING SMALL AMTS OF CLEARS. ON BEDPAN MULTIPLE TIMES AND UP TO THE COMMODE X1 FOR LIQUID STOOL. BROWN. ABD FIRM AND DISTENDED. BS'S PRESENT.\nRENAL: VOIDING AMBER COLORED URINE. IN SMALL AMTS.\nNEURO: ALERT AND ORIENTATED, BUT VERY NEEDY, WANTS TO CONTROL HIS CARE AND STATES HE'S TIRED OF THE WHOLE BUSINESS. ATIVAN 0.5MG PO GIVEN Q6HRS WITH MOD. EFFECT.\nCV; VERY EDEMATOUS. HEMODYNAMICALLY STABLE. ONLY WANTS HIS BP TAKEN Q4HRS.\nID: ? TO IR FOR GALLBLADDER DRAIN INSERTION-ON HOLD FOR TODAY. AFEBRILE, BUT FEELS WARM. NO C/O ABD PAIN WHEN ASKED. U/S OF LIVER-SMALL AREA OF ASCITIS.\nACCESS: IV NOTIFIED FOR PICC LINE PLACEMENT-HASN'T COME YET.\nPLAN: POSSIBLE BONE MARROW IN FUTURE. ? OF DRAIN PLACMENT.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-14 00:00:00.000", "description": "Report", "row_id": 1575872, "text": "Patient is 55 year old male with history HIV diagnosed , on and off HAART regimens, alcohol abuse, COPD and PCP presents with fever, anasarca, diffuse lymphadenopathy and hypotensive 80's ? due to diarrhea. placed on code sepsis after BP unresponsive to fluid boluses given at ED.\n\nNeuro: alert and oriented x3, receives ativan 0.5mg for anxiety with moderate effect; tylenol for chronic back pain. Moves all extremeties but weak, needs assistance with activities. Slept intermittently. Refused to use pneumoboots, takes off his O2 intermittently.\n\nRespi: on and off O2 at 3 lpm via nsal cannula, satting >95%, lung sounds rhonchorous RL, exp wheeze LUL, dim LLL; exertional dyspnea with transfer from bed to commode or even with repositioning. less episode of coughing noted. pleural effusion per CXR ,may be related to ascitis.\n\nCV: refused BP taking eveyr hour, hemodynamically stable SBP 110-130's ST-SR 96-103 without ectopy, denies chest pain. pedal pulses palpable, + edema lower extremeties, ascitis.\n\nGI/GU: bowel sounds present, firm distended abdomen, denies pain. diarrhea x 1( brown liquid c-diff negative ) on regular meal, problem swallowing. ascitis with no tappable areas of fluid in abdomen. post ERCP/MRCP per GI schedule of gallbladder drainage not to be done tomorrow, no evidence of cholangitis. vioding to amber colored urine approximately 100-150cc/3-4hrs\n\nAccess: precept catheter wnl, plan for PICC line insertion tomorrow; talked with IV nurse they will be patient in am.\n\nID: afebrile, continues on vacomycin and meropenem.\n\nSocial: DNR/DNI lives alone after his partner died in , social work unable to contact his sister with the phone number given; looks depressed and withdrawn, cooperative with care although refused BP taken every hour, pneumoboots; patient also refusing bone marrow biopsy for diagnosis of MAC / lymphoma\n\nplan:\n\nPICC line insertion; replete lytes as needed; provide support with coping; possible call out to floor if patient remains stable; PRN neb treatments for respiratory distress/exertional dyspnea;\n" }, { "category": "Nursing/other", "chartdate": "2180-04-14 00:00:00.000", "description": "Report", "row_id": 1575873, "text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent Neb with mask. Tolerated well. BS expiratory wheezes R mid to lower lung fields, L lung clear. RR 21, HR 95. Pt. wearing 3lpm nasal prongs with O2 sats 95-98%.\nBS clear post RX. Pt. appears comfortable. See Carevue for treatment times.\nPlan: Will continue to follow with Nebs Q6prn.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-14 00:00:00.000", "description": "Report", "row_id": 1575874, "text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details..\n\nA&O. Stated he is sick of being sick and wants to be left alone and he is \"too weak\" to use the commode.\nHaving frequent sm stools in A.M. and occ incontinent of stools and urine. Refusing rectal bag and condom cath. Apetite . Plan for TPN this eve.\n\nGiven 20mg IV Lasix and 25gm Albumin. Has been voiding ~ 100cc q1hr. Currently he is ~100cc neg not including multiple episodes of incontinence of urine.\n\nFiO2 alternates between RA and 3/L N/C. O2sats 90s all day. Continues w/DOE and exertional exp wheezes. Prn albuteral/atrovent with good relief.\n\nBone Marrow Bx done at bedside. Tol procedure fairly well.\n\nT max 99.5 po. On Vanco and Merepenum.\n\nBP stable but HR 110-120s. Up to 150s after Bx.\n\nFriend in to visit x2 today.\n\nPr is DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-18 00:00:00.000", "description": "Report", "row_id": 1575885, "text": "MICU/SICU NPN ICU Day #12\nBriefly this is a 55 yo man with PMH: end staged AIDS, HCV who was admitted after several days of nausea/vomiting/diarrhea/malaise. He was admitted on the sepsis protocol and was aggresively hydrated, and covered with broad spectrum antibiotics. ICU course complicated by cyclical FUO and recurrent diarrhea. Pt was ruled out for C-diff and parasitic infection, all cultures to date have had no growth. Pt's mental state has deteriorated over the course of admission, he has become more depressed and withdrawn each day.\n\n\nS: \"I'm very sick.\"\n\nO:\n\nNeruo: pt is withdrawn and lethargic, frequently requesting medication for sleep and reporting difficulty sleeping, by report pt slept most of yesterday refusing ADL's and physical therapy, pt also reports high state of anxiety and near panic states, pt denies pain, MAE reluctantly\n\nPulm: LS CTA, SpO2 94%RA, pt had one episode of acute wheezing which occurred concurrently with pt's report of anxiety attack, med x1 with ipatropium neb\n\nCV: AVSS, please see flowsheet for data\n\nInteg: skin is C/W/D/I\n\nGI/GU: abd soft, NT/ND, BS present, tolerating full liquids without difficulty, and currently on TPN, voiding small amts clear amber urine frequently in urinal\n\nAccess: left brachial DL PICC day #4\n\nA:\n\nanxiety r/t hospitalization/depression\nhigh risk for infection r/t neutropenia, invasive line\n\nP:\n\ntransfer to medical bed when available, activity progression, psyhciatry consult re: anxiety/depression\n" }, { "category": "Nursing/other", "chartdate": "2180-04-18 00:00:00.000", "description": "Report", "row_id": 1575886, "text": "Pt asleep most of the latter night. Last rx neb with atrovent @ 0100. No wheezing noted. Pt had been given ativan and quickly fell back to sleep\n" }, { "category": "Nursing/other", "chartdate": "2180-04-18 00:00:00.000", "description": "Report", "row_id": 1575887, "text": "MICU NPN for days: DNR/DNI\n\n Please see flowsheet for more details\n\nNeuro: Episode x 1 of \"pain attack\" and requesting ativan. Given and pt. slept most of the day. Easily arousable and conversed when awake. Oriented x 3. PERLA. MAE. Weak/ effort w/ turning/repositioning. Refused to get oob to chair today. Denies any pain/discomfort.\n\nResp: Remains on RA w/ stable o2 sats. Lungs w/ one episode of exp. wheezing w/ clearing after Rt administered neb tx. Otherwise, lungs CTA. Productive cough of clear sputum. RR tachypneic w/ activity.\n\nCV: ST 110-120's. No ectopy. Spiked to 101.8. Given tylenol 650mg po. + ppp x 4. Conts. w/ generalized body edema.\n\nAccess: DL PICC to LAC w/ dressing changed today.\n\nGI/GU: + hypoactive BS. Ascites. No BM. Voids small frequent amts in urinal, but also incont in bed.\n\nSKIN: Noted coccxy area to reddened and applied barried cream. Otherwise, no other breakdown noted.\n\nPlan: Cont. w/ current plan of care. Repleting lytes as needed. Monitor per protocol. Called out to bed and awaiting bed availability.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-09 00:00:00.000", "description": "Report", "row_id": 1575854, "text": "MICU/SICU NPN ICU Day #3\nEvents: bolused x2 for hypotension/tachycardia\n\nS: \"I just wish I knew what's wrong, I'm very anxious.\"\n\nO:\n\nNeuro: pt is A&Ox3, MAEW, denies pain, transfers bed to commode with supervision, very anxious\n\nPulm: LS CTA, SpO2 96-99% RA, strong cough occasionally productive\n\nCV: HR 100-128 SR/ST without appreciable ectopy, BP 79-125/46-87, CVP 13-18, please see flowsheet for data\n\nInteg: C/W/D/I\n\nGI/GU: abd is softm NT/ND, BS present, tolerating full liquids without difficutly, multiple sot/liquid BM on commode, voiding small amts amber urine frequently\n\nAccess: right IJ PreSept cath day #3, PIV x2\n\nA:\n\nanxiety r/t hospitalization, diagnosis\nhigh risk for infection r/t invasive line\nfluid volume deficit r/t GI losses\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue abx as ordered and follow micro data, ADAT, activity progression, aggressive pulmonary toilet\n" }, { "category": "Nursing/other", "chartdate": "2180-04-09 00:00:00.000", "description": "Report", "row_id": 1575855, "text": "Addendum to NPN\nPt spiked to 103.7 ax, unable to obtain oral temp d/t pt agitation, blood cultures x2 including fungal isolator sent, team notified. med x1 with APAP 650 PO. continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-09 00:00:00.000", "description": "Report", "row_id": 1575856, "text": "NPN 0700-1900\n\nEvents: Temp spike to 102.2ax with HR to 150's and severe coughing spasm. CXR indicates pna. Bolused with total of 1500cc LR for tachycardia and hypotension.\n\nNeuro: A&O, lethargic at times. OOB to commode with minimal assist, weak but steady gait.\n\nCV: NBP 78-152/48-78, 1L LR bolus given for NBP 78/48; HR 97-154, SR/ST -> EKG done when HR up to 150's -> SVT and a-fib ruled out, NBP with increased HR was 150's/80's, given 500cc LR bolus. Pt denies CP, echo ordered to R/O endocarditis. Crit at 1600 19.8 (7pt drop) ?hemolysis -> to be transfused with 2units PRBC's.\n\nResp: O2 sat 88-99% on 3L NC, lung sounds remain clear, diminished lower bases, RR 23-37, labored at times; coughing spasms occurring with spikes in temp -> dry NP, no relief with guafenisen w/codeine -> lidocaine neb and benzoate tabs ordered. CXR this am suspicious for RLL pna.\n\nGI: Abdomen softly distended, slight tenderness lower quads, +BS, small to medium loose stools. #3 spec for C. diff sent. Pt advanced to BRAT diet. Apetite fair.\n\nGU: Voiding small amts amber urine in urinal and commode, also occasionally incontinent. 24hr fluid status is +2500, LOS +. Received total of 1500cc IV fluid boluses.\n\nID: Tmax 102.2ax, current 101.6. Received tylenol X1. Remains on levo, flagyl, cefapime, vanco. Vanco trough this am 11.6\n\nPlan: Monitor temp, follow cultures, CXR, continue broad coverage abx; monitor hemodynamic status, LR IVF boluses for hypotension and tachycardia; monitor crit and hemolysis labs; monitor fluid/electrolyte status, replete prn.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-09 00:00:00.000", "description": "Report", "row_id": 1575857, "text": "RESPIRATORY CARE: PT W/ EPISODES OF TACHYCARDIA/ TACHYPNEA\nAND WHEEZING ASSOCIATED W/ INTRACTABLE COUGH. PT GIVEN A SVN\nW/ ATROVENT AND 1 % XYLOCAINE FOR WHEEZE/ COUGH. SUB/OBJ.\nBENEFIT BUT UNCLEAR WHETHER WAS DUE TO ATROVENT/XYLOCAINE.\nPT ALSO RECIEVED CODIENE FOR COUGH RN. NO SPUTUM\nOBTAINED TODAY. WILL F/U IN AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-07 00:00:00.000", "description": "Report", "row_id": 1575849, "text": "RESPIRATORY CARE: PT IS A 55 YO MALE PT\nW/ AIDS WHO NOW PRESENTS W/ FEVER/\nMALAISE AND MILD SOB. PT GIVEN A NEB.\nTX W/ ALBUTEROL/ ATROVENT FOLLOWED BY\nHYPERTONIC SALINE AEROSOL X 20 MINUTES\nTO ATTEMPT A SPUTUM INDUCTION FOR PCP.\n PENDING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1575881, "text": "1900-0700hrs\n\nEvents: 55yo male with H/O HIV,COPD,PCP, with fever malaise,and diarrhea,admitted in ICU for observation following hypotension and sepsis.\n\nNeuro:pt alert ,oriented well,anxious ,c/o insomnia,received 2.0mg Tab.Ativan and slept after that.\n\nResp:On RA ,RR 18-26/,Spo2 93-98%,c/o SOB at 2300hrs,felt comfortable after resp.treatment.Breath sounds diminished on base and expiratory wheeze present.\n\nCVS:HR 116-130/,,no ectopics,BP WNL,pulse+ on extremities with edema.PICC line on Lt.ante cub.\n\nGI:On regular diet,with little appetite,on TPN 60ml/hr,abdomen firm and distended,bowel sounds hypoactive,no bowel movement this shift.\nreceived Tab.Lopremide 2.0mg po.\n\nGU:Voids good amount of urine,clear amber coloured,having scrotal swelling and c/o scrotal discomfort and requested for warm wet cloth to apply to the scrotum.\n\nINTEGU:T.max 99.7, skin intact,generalised edema present.\n\nIV ACCESS:Lt.ante.cub PICC line,placed on ,dressing intact,line patent\n\nSocial:Calm and co-oprative,no visitors this shift,DNR,with universal precautions.\n\nPlan:Continue TPN,and antibiotics,GI to follow up,treat diarrhea with immodium and Ativan for anxiety.continue with respiratory and physical therapy.AM labs sent.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1575882, "text": "Resp care,\nPt. given albuterol/atrovent neb x 1. Pt. c/o SOB. BS crackles, no wheezes. Relief with rx. Cont. nebs prn.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1575883, "text": "MICU EAST NPN 0700-1900\n\n\nPlease see flowsheet for further details...\n\n\nA&O. Withdrawn and depressed. Wanting to sleep all day. Refusing to get OOB though did get OOB-chair x 1 for ~20min, as bed was saturated with urine. Needed 2 assists. Refused PT. Inc of urine after lasix but refusing condom cath. Much weaker this week than last week. No stool. Given albumin and IV Lasix and is currently diuresing. Apetite remains . Continues on TPN. PICC catheter ?out more than last week. CXR ok per Dr. . Total length of catheter outside of vein measured at 7cm. Plan to monitor. Bleeding mod amt at site after dsd change (d/t old blood under dsd). Placed on neutrapenic precautions. No visitors though pt had phone call in room.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1575884, "text": "Respiratory Care:pt seen for albuterol/atrovent neb x 1. Lung sounds expiratory whezees, no C/O SOB, did not required further txs. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-08 00:00:00.000", "description": "Report", "row_id": 1575850, "text": "MICU/SICU NPN ICU day #2\nEvents: bolused x1 with 500cc NS for CVP <12\n\nS: \"I'm very anxious, near panic.\"\n\nO:\n\nNeuro: pt is A&Ox3, generally anxious, med x1 with IV lorazepam with good effect, CIWA scale 4-11\n\nPulm: LS CTA, SpO2 93-100% RA\n\nCV: HR 98-122 SR/ST without appreciabel ectopy, BP 95-123/44-71, CVP 8-14, please see flowsheet for data\n\nInteg: C/W/D/I\n\nGI/GU: abd soft, NT/ND, hyperactive BS, tolerating clear liquids without difficulty, multiple liquid BM overnight, voiding small amts amber urine in urinal frequently\n\nAccess: right IJ PreSept cath day #2, PIV x2\n\nA:\n\nacute on chronic anxiety r/t hospitalization, diagnosis\nfluid volume deficit r/t diarrhea, N/V\nhigh risk for infection r/t invasive line\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, ADAT, activity progression, continue abx as ordered and follwo micro data,transfer to medical bed when available\n" }, { "category": "Nursing/other", "chartdate": "2180-04-08 00:00:00.000", "description": "Report", "row_id": 1575851, "text": "Resp: Pt ordered for nebs of Alb/Atr. Bs are diminished bilaterally. No adverse reactions following neb. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-08 00:00:00.000", "description": "Report", "row_id": 1575852, "text": "RESPIRATORY CARE: PT SEEN FOR AN INDUCED SPUTUM FOR PCP\nAND AFB ( NOT TB ) USING INDUCTION PROTOCOL W/ 3 %\nHYPERTONIC SALINE AEROSOL. SPECIMEN OBTAINED AND SENT\nTO LAB. RESULTS PENDING. WILL REPEAT IN AM. APPEARS\nCOMFORTABLE W/ SPO2 97 % ON RA.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-08 00:00:00.000", "description": "Report", "row_id": 1575853, "text": "NPN 0700-1900\n\nGeneral/Events: Temp still spiking - up to 103.3 this am; late afternoon felt worse with diarrhea, coughing spasms and another spike in temp to 103.6ax with tachycardia -> 500cc NS fluid bolus X1 given.\n\nNeuro: A&O X3, lethargic at times but was up in chair for an hour early afternoon. Gait steady, says he felt stronger than he has in awhile. Given ativan .5mg X1 for c/o anxiety with good effect. Discouraged in afternoon when symptoms worsened.\n\nCV: NBP 89-156/49-85, HR 103-130's, ST -> given 500cc NS fluid bolus X1 for tachycardia, did not have hypotension with increased HR. No peripheral edema, pulses strong and palpable. Crit stable at 27, platelets 66.\n\nResp: O2 sat 92-97% on RA, 99-100% on 2-3L; lung sounds are clear upper lobes, diminished lower. Has a frequent dry nonproductive cough that comes in spells, little relief from robitussin so robitussin with codeine ordered. Sputum spec sent after receiving humidified O2, pt able to expectorate small amt.\n\nGI/FEN: Abdomen firm, less distended than yesterday, NT, +BS, had small to medium amt of loose brown stool -> spec sent for C. diff. Tolerating clear liquids, wants solid food.\nMag of 1.8 repleted with 400mg mag oxide.\nPhos of 1.5 repleted with 1 packet of neutra-phos.\nK of 3.3 repleted with 60meq KCL tabs.\n\nGU: Voiding 150-200cc at a time; fluid balance since midnight is +645, LOS +8L.\n\nID: Tmax and current 103.6ax, continues on levo, flagy, vanco, cefapime. Urine, stool and sputum specs sent today.\n\nPlan: Monitor temp, follow cultures, continue antibiotics; monitor hemodynamic and fluid/electrolyte status -> fluid boluses for hypotension, tachycardia, low urine output, replete lytes prn\n" }, { "category": "Nursing/other", "chartdate": "2180-04-11 00:00:00.000", "description": "Report", "row_id": 1575862, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. VERY FRUSTRATED THROUGHOUT SHIFT. CONTINUES TO REFUSE TO WEAR O2 EVEN WITH SATS IN MID TO HIGH 80'S. PT. IS DNR. INCONTINENT OF URINE MULTIPLE TIMES BUT REFUSING CONDOM CATH. PT. CONTINUES TO SPIKE TEMPS. GIVEN TYLENOL 650MG AT MIDNIGHT WITH GOOD RESULT. MEROPENEM ADDED TO ANTIBIOTIC THERAPY. K+ OF 3.5 REPLETED WITH 40MEQ KCL IV.\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. OOB TO COMMODE WITH ASSIST. NO C/O PAIN.\n\nRESP: PT. ON R/A WITH SATS MID 80'S TO LOW 90'S. AS STATED ABOVE, REFUSES TO WEAR O2. BREATH SOUNDS CLEAR. DIMINISHED IN BASES. EXP. WHEEZES AND DYSPNEA NOTED WITH EXCERTION. NONPRODUCTIVE COUGH NOTED.\n\nCV: PT. NSR/ST. NO ECTOPY NOTED. SBP HIGH 80'S TO LOW 100'S. MAP >60. + PULSES. NO EDEMA. TMAX 101.9 AXILLARY\n\nGI: PT. ON DIET WITH VERY APPETITE. ABD. SOFT. BS+. NO BM THIS SHIFT. WHEN PT. DOES HAVE BM PLEASE SEND SAMPLE FOR CDIFF B TOXIN (SEE PENDING LABS)\n\nGU: VOIDING IN URINAL AND INCONTINENT MULTIPLE TIMES IN BED. OUTPUT INACCURATE.\n\nSKIN: INTACT\n\nACCESS: R IJ PRECEP CATH DAY #5\n 1 PIV\n\nPLAN: CONTINUE WITH CURRENT POC. TYLENOL PRN FOR TEMPS. AGGRESSIVE ANTIBIOTIC THERAPY AS PT. DOES HAVE PNEUMONIA AND ACUTE CHOLECYSTITIS. ACTIVITY AS TOLERATED, AGGRESSIVE PULM. TOILET.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-11 00:00:00.000", "description": "Report", "row_id": 1575863, "text": "npn 0700-1900;\nevents;mrircp to r/o cholelithiasis but study due to ascitis and pt having high rr.did not complete study.\nct scan of chest r/o pnx preliminary report showing fluid awaiting official read..\n\nneuro; pt remains frustrated with being ill and weak and with constant interruptions refusing to wear oxygen and pneumo boots refusing to wash etc. wants to go home.\n\nresp ;lungs coarse upper with expiratory wheeze improves with neb treatments strong productive cough swallows most of it.sat90-94% on ra. 99% on hi flow neb rr 30-37.very diminished at bases at times.\n\ncvs; tmax 99. 100 no observed ectopy.bp 88-114/60-70.\n\ngu; low urine output icterict urine incontinent of urine x2 mod amounts bladder scan prior to mri amd prior to second incontinence showed 350-475 mls. foley considered ,but held in light of low wbc.\n\ngi; belly firm distended pos bs bm x2 soft. formed stool with /bile colour .guaiac neg, npo 10 am for mriercp. eating min amounts\n\nskin;intact very dry refusing care but encouraged to move around bed and move legs frequently to avoid clots.\n\nsoc; pts talked to several people on ,phone friend into visit,\n\na/p; npo after mn for pos ercp in am. follow labs follow up on cultures\nc/o that \"anxiety level is way up there!\" offer ativan round the clock. feels that it helps greatly.\nneed spec for c-diff.\nfollow up on ct scan results of chest ? needs diuresis to help improve resp status.\nspoke with lisw who will try and see him tomorrow.\ncontinue to monitor urine outut closely.\nfollow labs for neuropenia, hit screen pending.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-16 00:00:00.000", "description": "Report", "row_id": 1575878, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. REMAINED STABLE THROUGHOUT SHIFT STATING \"I FEEL BETTER TONIGHT\". PRN NEBS FOR OCCASSIONAL EXPIRATORY WHEEZING. PROBABLE C/O TO FLOOR TODAY\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. ASSISTS WITH NSG. CARE. NO C/O PAIN. PHYSICAL THERAPY TO EVALUATE TODAY AS PT. ANXIOUS TO GET UP AND MOVING.\n\nRESP: PT. ON AND OFF 3L NASAL CANNULA WITH SATS REMAINING >94% ON R/A. REMAINS WITH DOE. BREATH SOUNDS COARSE BILAT. SOME EXP. WHEEZES NOTED WHICH CLEAR WITH NEB TREATMENTS. ORDER WRITTEN TO OBTAIN SPUTUM, HOWEVER, PT. UNABLE TO EXPECTORATE.\n\nCV: NSR/ST. NO ECTOPY NOTED. BP WNL. + PULSES. SCROTAL EDEMA NOTED. PT. REMAINS WITH LOW GRADE TEMP. CULTURED YESTERDAY .\n\nGI: ABD. FIRM/DISTENDED. + ASCITES. ON DIET, HOWEVER VERY APPETITE. REMAINS ON TPN. MULTIPLE SMALL LOOSE BMS THIS EVENING.\n\nGU: VOIDING IN URINAL.\n\nSKIN: INTACT\n\nACCESS: L AC PICC\n\nPLAN: ? C/O TO FLOOR. CONTINUE WITH ANTIBIOTIC THERAPY. MONITOR RESP. STATUS CLOSELY. PRN NEBS AS NEEDED. CONTINUE WITH ENCOURAGEMENT AND EMOTIONAL SUPPORT. DNR/DNI. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-16 00:00:00.000", "description": "Report", "row_id": 1575879, "text": "Resp Care,\nPt. given albuterol/atrovent nebs x 2 this shift. Becomes wheezy with exertion, clears with rx. O2 3l. Will cont. to follow with nebs prn wheezes.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-16 00:00:00.000", "description": "Report", "row_id": 1575880, "text": "7A-7PM Nsg Progress Note\nEVENTS: pt continues with low grade fevers, dyspnea with exertion, OOB to chair (PT saw pt) pt diuresed pt declined thoracentesis\n\nRESP: pt on RA, O2 sats 92-96% lungs w/ decreased breath sounds, exp wheezes.\n\nCV/FLUIDS: bp stable 120/72 HR 100-120 ST no vea noted. + pedal pulses, lower extremities edematous. pt received 12.5 grams of Albumin, 20 mg IVP lasix ~ with good response 1150 cc's.\n\nID: temp 100.4 po, WBC 1.1 gran ct 690, stool for C-diff negative, urine negative.\npt remains on Vanco and Meropenem. Vanco trough level 15\nsputum sample sent.\n\nGI: ABD firm, distended, po intake, nsg encouraging pt to eat. remains on TPN @ 42 cc/hr. continues with diarrhea, OB negative. guiac negative. pt received 4 mg Loperamide po x1.\n\nGU: pt voiding in urinal\n\nSKIN: intact, scrotal edema, anasarca with pleural effusions and ascites.\nPT following pt. OOB to chair - pt took few steps,\nstill very weak.\n\nNEURO: pt A+Ox3, wanting to nap all shift, after bed changed, pt SOB, requesting .5 mg po Ativan (given with good affect)\n\nIV ACCESS: left antecubital PICC inserted , dsg changed, intact, flushes well.\n\nPLAN: overall source of infection unclear, awaiting bone marrow biopsy data, GI to follow up on Monday, ?colonoscopy, treat diarrhea with Imodium, continue TPN, physical therapy following pt, OOB to chair, albuterol/atrovent MDI's prn enc po intake, follow temp, continue antibx,\n" }, { "category": "Echo", "chartdate": "2180-04-10 00:00:00.000", "description": "Report", "row_id": 97903, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 70\nWeight (lb): 147\nBSA (m2): 1.83 m2\nBP (mm Hg): 120/66\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 10:33\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal IVC diameter with >50% decrease during\nrespiration (estimated RAP 5-10 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or vegetation on\nmitral valve. Mild (1+) MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - echo windows.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 5-10 mmHg. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. No masses or vegetations are seen on the aortic\nvalve. The mitral valve leaflets are structurally normal. There is no mitral\nvalve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+)\nmitral regurgitation is seen. The left ventricular inflow pattern suggests\nimpaired relaxation. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2180-04-07 00:00:00.000", "description": "Report", "row_id": 266524, "text": "Sinus tachycardia, rate 105. Since the previous tracing the heart rate is\nfaster. No other changes are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2180-04-06 00:00:00.000", "description": "Report", "row_id": 266525, "text": "Sinus rhythm, rate 83. Low voltage is present throughout the electrocardiogram.\nThe Q-T interval is borderline prolonged. Minor ST-T wave abnormalities are\nseen. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2199-06-27 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1148558, "text": " 7:35 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute abd process?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with c/o of total body pain, epigastric discomfort and nausea\n and vomiting x 5 episodes this AM\n REASON FOR THIS EXAMINATION:\n eval for acute abd process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:20 AM\n no acute abnormality. 15mm endometrium, similar to that seen previously.\n Given the patient's age, this should be further evaluated with outpatient\n son\n WET READ VERSION #1 9:18 AM\n no acute abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Epigastric discomfort, nausea and emesis.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis\n following administration of 130 ml of intravenous Optiray contrast. Coronal\n and sagittal reformatted images were also reviewed.\n\n CT ABDOMEN WITH CONTRAST: The imaged portions of the lung bases are notable\n for bibasilar subsegmental atelectasis. The visualized portion of the heart\n is normal. The spleen, pancreas, adrenal glands, gallbladder are\n unremarkable. A small amount of relative hepatic hypodensity adjacent to the\n ligamentum teres reflects focal fatty infiltration. The kidneys enhance and\n excrete contrast in a symmetric fashion. Note is made of right renal\n hypodensities, which are too small to characterize, but likely small cysts.\n No bowel obstruction or wall thickening is seen. Regional vascular structures\n are unremarkable. There is no retroperitoneal or mesenteric lymphadenopathy.\n There is no free gas or free fluid in the abdomen. Note is made of a\n fat-containing umbilical hernia.\n\n CT PELVIS WITH CONTRAST: The urinary bladder, distal ureters, colon and\n appendix are unremarkable. Prominent endometrium (15mm) is again noted.\n There is no free gas or fluid in the pelvis. There is no pelvic sidewall or\n inguinal lymphadenopathy.\n\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\n There is loss of intervertebral disc height at the lumbosacral junction.\n\n IMPRESSION:\n 1. No acute intra-abdominal or pelvic process to explain the patient's\n symptoms.\n 2. Fat-containing umbilical hernia.\n 3. Prominent endometrium (15mm), also noted on the prior CT from 03/. In\n (Over)\n\n 7:35 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute abd process?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n a patient of this age (presumed post-menopasual), recommend further evaluation\n with outpatient pelvic ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2199-06-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1148550, "text": " 6:04 AM\n CHEST (PA & LAT) Clip # \n Reason: acute CT process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with c/o of fever and nausea and vomiting, eval for acute CT\n process\n REASON FOR THIS EXAMINATION:\n acute CT process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, nausea and emesis.\n\n COMPARISON: .\n\n TWO VIEWS OF THE CHEST: Cardiac, mediastinal and hilar contours are normal.\n A right peripherally inserted central catheter has been removed. Lung volumes\n are low and note is made of mild bibasilar atelectasis. Mild prominence of\n central pulmonary vasculature is stable and there is no pulmonary edema.\n There is no pleural effusion or pneumothorax.\n\n IMPRESSION: No acute intrathoracic abnormality.\n\n" }, { "category": "ECG", "chartdate": "2199-06-27 00:00:00.000", "description": "Report", "row_id": 163472, "text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2199-06-27 00:00:00.000", "description": "Report", "row_id": 163473, "text": "Sinus tachycardia. Inferolateral slight ST segment depression. Compared to the\nprevious tracing of the rate has increased. There are non-specific\ninferolateral ST segment changes and low amplitude T waves. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2199-06-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1148604, "text": " 12:20 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with new L IJ\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New left internal jugular central venous line, please evaluate\n for location.\n\n COMPARISON: Chest radiograph from same day.\n\n BEDSIDE FRONTAL VIEW RADIOGRAPH OF THE CHEST: A left internal jugular central\n venous line is new, with the tip ending at the upper portion of the superior\n vena cava. Cardiac, mediastinal, and hilar contours are stable. The lungs\n are again clear. There is no pleural effusion or pneumothorax.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2134-06-05 00:00:00.000", "description": "Report", "row_id": 117988, "text": "Sinus bradycardia. Borderline P-R interval prolongation. Leftward axis.\nLate R wave progression may be related to left anterior fascicular block.\nClinical correlation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2134-06-19 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 917353, "text": " 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: R/O retroperitoneal Bleed\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p 2 cath procedures in past week, with dropping Hct.\n REASON FOR THIS EXAMINATION:\n R/O retroperitoneal Bleed\n CONTRAINDICATIONS for IV CONTRAST:\n pt with 2 contrast loads this week thus far\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post two cardiac catheterizations with decreasing hematocrit.\n Evaluate for retroperitoneal hematoma.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial multidetector CT images of the abdomen and pelvis were\n obtained without intravenous or oral contrast.\n\n ABDOMEN CT WITHOUT CONTRAST: There is linear atelectasis at the left lung\n base. There is a small amount of pericardial fluid, which may be within\n physiologic limits.\n\n The liver, gallbladder, spleen, pancreas, adrenal glands, and unopacified\n bowel loops appear unremarkable on limited non-contrast evaluation. Multiple\n foci of cortical scarring are noted in the left kidney. There is minimal\n residual contrast, likely from preceding cardiac catheterizations, in the\n collecting systems of both kidneys. There is no free fluid or evidence of\n hematoma in the abdomen. Extensive atherosclerotic vascular calcifications\n are present.\n\n PELVIS CT WITHOUT CONTRAST: There is a Foley catheter in the bladder. There\n is a large amount of stool in the rectum. The uterus and adnexa are not well\n assessed on limited non-contrast exam. There is soft tissue density\n surrounding the right external iliac vessels, compatible with a small\n hematoma. The muscles and other soft tissues of the right pelvic sidewall and\n the right hip appear expanded compared to the left side, consistent with edema\n which may be secondary to hematoma. The psoas muscles also appear asymmetric,\n right larger than left. However, fat planes around the upper and mid portions\n of the right psoas muscle are preserved, and the asymmetry is likely related\n to the patient's scoliosis.\n\n BONE WINDOWS: There is thoracolumbar scoliosis with associated degenerative\n changes. There is a sharply marginated defect in the right posterior ilium\n adjacent to the sacroiliac joint (series 2, images 53 through 58). There is a\n right hip prosthesis. There is a dynamic screw with a side plate in the\n proximal left femur.\n\n Presence of a small right pelvic hematoma, as well as a hematoma in the right\n hip muscles, was discussed with Dr. at 2:30 p.m. on .\n\n (Over)\n\n 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: R/O retroperitoneal Bleed\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Small hematoma adjacent to the right external iliac vessels. Hematoma is\n expanding the muscles and soft tissues over the right hip/groin.\n\n 2. Small amount of pericardial fluid, which may be physiologic.\n\n 3. Sharply marginated defect in the right ilium, which may represent a\n previous bone graft donor site. Correlation with previous surgical history is\n suggested.\n\n\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2134-06-10 00:00:00.000", "description": "MRA PELVIS W&W/O CONTRAST", "row_id": 916079, "text": " 3:20 PM\n MRA ABDOMEN W&W/O CONTRAST; MRA PELVIS W&W/O CONTRAST Clip # \n MRA LOWER EXT W&W/O CONTRAST; BILATERAL\n MR CONTRAST GADOLIN\n Reason: Please eval R foot/R lower extremity in prep for ?peripheral\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe peripheral vascular disease and cellulitis in R\n foot\n REASON FOR THIS EXAMINATION:\n Please eval R foot/R lower extremity in prep for ?peripheral stenting\n ______________________________________________________________________________\n FINAL REPORT\n MRI SCAN OF THE AORTA AND LOWER EXTREMITIES (MR ANGIOGRAM PROTOCOL)\n\n TECHNIQUE: 3-Tesla MRI with intravenous gadolinium postop time-of-flight\n series, TRICKS sequence of the right below knee arteries and MR angiogram of\n the aortoiliac and both lower extremities.\n\n RECONSTRUCTIONS: Subtraction images and multiplanar reformations on and MIP\n images of the arterial anatomy performed in an independent workstation.\n\n CLINICAL DETAILS: Peripheral vascular disease. Right foot cellulitis,\n evaluate for arterial lesions.\n\n No prior imaging for comparison.\n\n FINDINGS:\n\n Technically suboptimal examination due to some patient motion during the exam\n and large susceptibility artifact from right hip prosthesis over the lower\n right iliac and proximal right femoral area.\n\n AORTOILIAC:\n The abdominal aorta is normal in caliber throughout measuring less than 2 cm.\n Minor atheromatous plaque along its length, no focal stenosis. Each kidney is\n supplied by a single renal artery, minor area of focal plaque 1 cm from the\n right renal artery ostium (series 17B, image 37).\n The proximal right common iliac artery is normal in caliber but there is focal\n high-grade stenotic narrowing in the distal portion of the right common iliac\n to proximal right extrnal artery over at least 2 cm in length. The more distal\n right external iliac artery, right common femoral artery and part the proximal\n right superficial femoral arteries are obscured by susceptibility artifact\n from metallic artifact on the left side.\n Left common and exernal iliac arteries are patent and normal in calibe. No\n high grade stenosis, focal areas of plaque in the proximal left common, mid\n left common and distal left external arteries.\n\n RIGHT LOWER EXTREMITY:\n Right common and proximal third of the right superficial femoral artery are\n not visualized due to susceptibility artifact from metal. Portion of the\n (Over)\n\n 3:20 PM\n MRA ABDOMEN W&W/O CONTRAST; MRA PELVIS W&W/O CONTRAST Clip # \n MRA LOWER EXT W&W/O CONTRAST; BILATERAL\n MR CONTRAST GADOLIN\n Reason: Please eval R foot/R lower extremity in prep for ?peripheral\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n proximal right SFA is patent followed by an area of long segmental occlusion\n (13 to 14 cm) in its mid portion. Reconstitution of a narrow caliber distal\n right SFA at the level of the adductor canal followed by a narrow caliber\n popliteal artery. The TRICKS series show the inferior (2cm at least) portion\n of the right popliteal artery to be widely patent. Right posterior tibial\n artery is occluded in its proximal portion. Patent anterior tibial artery, has\n multifocal areas of focal stenosis along its mid portion but remains patent\n distally and the dorsalis pedis artery is intact. The common peroneal artery\n gives rise to collaterals at the level of the ankle joint which track\n posteriorly and just below the level of the ankle joint, giving rise to un-\n named collaterals. A normal posterior tibial artery is not reconstituted\n distally.\n\n LEFT LOWER EXTREMITY:\n\n Patchy atheromatous plaque along the right external iliac artery, which is\n normal in caliber. Left common femoral artery is patent. Occlusion of the\n proximal third of the left SFA with reconstitution of the vessel in its mid\n portion. The left popliteal and left trifurcation are patent but\n suboptomially demonstrated. Assessment of the left below knee arteries is not\n possible due to patient motion on the MR angiogram phase.\n\n The kidneys measure 9 cm in length bilaterally and show symmetric post-\n contrast enhancement.\n\n RECONSTRUCTIONS: Multiplanar reconfirmations, subtraction images and maximum\n intensity projection images performed on independent workstation. These were\n helpful in displaying the arterial anatomy.\n\n CONCLUSION:\n\n Technically limited exam over the lower right iliac and proximal right femoral\n area due to metal artifact.\n\n 1. Multi-focal, multi-level right sided diesease.\n 2. Focal high-grade stenosis in the distal right common and visible proximal\n portion of the right external iliac artery. Occluded right superficial femoral\n artery, which is reconstituted at the level of the adductor canal. Occluded\n right posterior tibial artery. Patent right anterior tibial with focal areas\n of stenosis in its mid portion, patent right dorsalis pedis. Peroneal artery\n gives rise to un-named just above the level of the ankle.\n\n 3. Proximal occlusion of the left superficial femoral artery, with\n (Over)\n\n 3:20 PM\n MRA ABDOMEN W&W/O CONTRAST; MRA PELVIS W&W/O CONTRAST Clip # \n MRA LOWER EXT W&W/O CONTRAST; BILATERAL\n MR CONTRAST GADOLIN\n Reason: Please eval R foot/R lower extremity in prep for ?peripheral\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n reconstitution in its mid third.\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2131-06-05 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 760860, "text": " 9:08 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE;CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with coronary artery disease, preop for CABG.\n REASON FOR THIS EXAMINATION:\n Assess for infiltrate / failure.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, 2 VIEWS PA AND LATERAL:\n\n HISTORY: Pre op CABG.\n\n Heart size is normal. There is slight tortuosity of the thoracic aorta. No\n evidence for CHF. Linear atelectasis is present at the left base. Old rib\n fracture of right 6th rib. Calcification in anterior longitudinal ligament in\n thoracic spine.\n\n IMPRESSION: No evidence for CHF or pneumonia. Linear atelectasis left base.\n Equivocal COPD.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-06 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 760889, "text": " 9:35 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: evaluate for stenosis h/o CVA \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD for CABG on needs duplex by \n REASON FOR THIS EXAMINATION:\n evaluate for stenosis h/o CVA \n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Prior history of stroke. Preop for CABG. Evaluate carotid\n disease.\n\n CAROTID SERIES: Duplex evaluation was performed of both carotid arteries.\n Minimal plaque was identified bilaterally.\n\n On the right peak systolic velocities are 100, 96, and 94 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 1. This is consistent with no\n less than 40% stenosis.\n\n On the left peak systolic velocities 71, 88, and 117 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.9. This is consistent with\n less than 40 percent stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Mild plaque with bilateral less than 40% carotid stenosis.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 761295, "text": " 11:43 AM\n CHEST (PA & LAT) Clip # \n Reason: S/P CABG, CT REMOVAL. PLEASE EVAL FOR EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Post CABG and chest tube removal.\n\n Comparison is made to pre-op study of at 21:11.\n\n FINDINGS: There has been interval CABG. The aorta is slightly unfolded.\n There is interval development of small bilateral effusions, and there is a\n small amount of bibasilar atelectasis. There is no pneumothorax and there are\n no focal areas of consolidations. An osseous deformity is seen at the\n posterior aspect of the right 7th rib. This is unchanged from the prior study\n and likely relates to a previous fracture now healed.\n\n IMPRESSION:\n 1) No pneumothorax.\n 2) Small bilateral pleural effusions.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-06-07 00:00:00.000", "description": "Report", "row_id": 1563279, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: INITIALLY SEDATED ON PROPOFOL GTT, REVERSALS GIVEN AND PT. AWOKE MAE TO COMMANDS AND NODDING APPROPRIATELY. AFTER EXTUBATION PT. A&OX3, C/O STERNAL DISCOMFORT MEDICATED WITH 2MG IVP MSO4 AND 30MG IVP TORDOL WITH GOOD RELIEF. SOFT WRIST RESTRAINTS D/C'D.\nCARDIAC: ARRIVING WITH LOW CO/CI, IMPROVING AFTER RECEIVING 2L LR AND 500CC HESPAN, CURRENTLY ON .1MCG/KG/MIN OF LEVOPHED AND MAINTANING SYS B/P >90 AND MAP'S >60, MILRINONE GTT REMAINS AT .25MCG/KG/MIN. ALSO CURRENTLY ON AMIODARONE FOR VENT. ECTOPY IN OR CURRENTLY AT 1MG/MIN. IABP CURRENTLY AT 1:1 SETTINGS WITH GOOD DIASTOLIC AUGMENTATION AND SYSTOLIC UNLOADING. L GROIN SITE C&D WITH DSD, + BPPP. CURRENTLY A-PACING AT 90 FOR UNDERLYING RYTHYM OF 70'S.\nRESP: BS DIMINISHED IN BASES, AMBUED & SUCTIONED FOR THICK TAN SECREATIONS. REVERSALS GIVEN AND WEANED AND EXTUBATED AT ~1630PM, PLACED ON 6L NP & 40% OFM WITH SAT'S >98%, WILL DRAW POST ABG. CT OUTPUT INITIALLY OOZY, ACT 110, COAGS WNL, SLOWING DOWN.\nGI/GU: HOURLY URINES BRISK ON ARRIVAL, RECEIVED 20MG IVP LASIX IN OR, CLEAR YELLOW URINE. - BS THRU-OUT, OGT D/C'D WITH EXTUBATION. BS CONT. TO BE COVERED WITH S.S. INSULIN.\nSOCIAL: WIFE AND KIDS INTO VISIT, UPDATE GIVEN. LG. FAMILY, CURRENTLY STAYING AT BEST WESTERN.\nPLAN: CONT. TO FAST TRACK AS TOLERATED. MAINTAIN IABP. WEAN LEVO AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-09 00:00:00.000", "description": "Report", "row_id": 1563284, "text": "Update\nO: cv status: sr on amiod iv-> po today. Bp stable on no pressors. Oob to chair w no orthostatic changes.Distal pulses + w doppler and weak palp at times. Rt leg drsg wrap this am after leg observed for s/s ^ bldg not apparent. No further ^ in oozing or hematoma noted.\n\n\nResp status: remains on np at 3 lpm w adeq sats. Strong prod cough but pt swallows sputum. Bilat brth snds coarse ^ lobes diminished at bases.\n\nGi status: Tol po flds well w small amts food.\n\nGu status: huo qs cl yellow urine.\n\nNeuro status: Awake alert oriented oob to chair w 2 assist & tol well.\n\nLabs: Repleted w 2prbc w post transfusion hct 26.\n\nA/P: s/p cab pod#2 w ^ ecchymosis and ooze overnoc in rt thigh region replaced w prbc x2 w stable hct 6hrs post transfusion.Rt leg incision stable no ^ size or further bldg noted.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-10 00:00:00.000", "description": "Report", "row_id": 1563285, "text": "PATIENT SLEEPING COMFORTABLE AFTER TYLENOL#3 2TABS GIVEN. INSTRUCTED WITH DB, DOING BEFORE FALLING ASLEEP.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-10 00:00:00.000", "description": "Report", "row_id": 1563286, "text": "PATIENT WITH QUIET NIGTH, SLEPT IN SHORT NAPS. LAST DOSE TYLENOL #3 AT MN. COUGHING BUT NOT RAISING YET. ENCOURAGED DB/COUGHING. STERNUM LEFT OPEN TO AIR. OLD CHEST TUBE SITES WITH NEW DSD. RLEG UPPER THIGH ECCYCHMOTIC , NEW DSD APPLIED , ALSO WRAPPED AGAIN.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-10 00:00:00.000", "description": "Report", "row_id": 1563287, "text": "UPDATE\nStable relatively uneventful day. Ready for transfer to 6 however no beds available at this time. Cv status: sr on po amiodarone w low normal bp subseq to po lopressor this am and diuresing. Ambulated in x 1 w 2 assist and oob to chair x several hrs tol well. Taking po food and flds well. No bm yet abd soft nontender.huo qs w copious diuresis w lasix 20 this am.Rt radial art line dc'd and pressure held x 15mins w no hematoma, area very ecchymotic prior to art line removal.Resp status: remains on np at 3 lpm w sats 94-96 range.Lungs very distant posteriorly w coarseness ^ lobes clears w coughing.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-11 00:00:00.000", "description": "Report", "row_id": 1563288, "text": "PATIENT WITH HR 55-65, ??? D/C LOPRESSOR, DOES HE REALLLY NEED THIS . GOOD DIURESIS AFTER LASIX GIVEN, CHECK WGT. IN AM. SLEEPING IN SHORT NAPS AFTER 2TABS TYLENOL GIVEN. PLAN TO GO TO IN AM. INCREASE AMBULATION. BEGINNING TO RAISE SPUTUM. PATIENT HAS DIFFICULT SWALLOWING PILLS, PLEASE CRUSH IF POSSIBLE.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-08 00:00:00.000", "description": "Report", "row_id": 1563280, "text": "NEURO: PT AWAKE ALERT FOLLOWING COMMANDS.\nRESP: O2 WEANED DOWN TO 3L NC WITH O2 SAT 97% PT COUGHING BUT NO RAISING. CHEST TUBES PATENT DRAINING SANGUINIOUS TO SEROUS SANG. DRAINAGE, AROUND 40CC/2HRS. PT 200CC THIS AM AFTER TURNING SIDE TO SIDE THIS AM.\nC/V: PACER OFF HEART RATE IN THE 70'S SINUS NO ECTOPY. PT ON AMIODARONE AT 0.5MG. PT 500CC HESPAN LAST EVENING FOR LOW BP AND FILLING PRESSURES WITH GOOD RESULLTS. LEVO TITRATED FOR BP PRESENTLY ON 0.02MCG/KG/MIN. CI OFF MILRINONE 2.36 TO 3.2. IABP ON 1:1 WITH GOOD AUGMENTATION. TURNED DOWN TO 1:2 AT 0500 WILL RECHECK NUMBERS AND PLAN FOR D/C LATER THIS AM.\nGI: NPO OVERNIGHT FOR POSSIBLE IABP REMOVAL.\nGU: GOOD URINE OUTPUTS.\nSKIN: INCISIONS CLEAN AND DRY. SMALL AMOUNT OF OOZING FROM UPPER ASPECT OF LEG INCISION.\nPAIN: PT C/O INCISIONAL ISCOMFORT NOT REALLY PAIN A ON SCALE GOOD PAIN RELIEF WITH MORPHINE AND TORODOL. PT DOES GET VERY ANXIOUS WITH MOVEMENT (TURNING IN BED)2ND TO BECOMES NAUSEOUS WITH TURNING. PT TREATED WITH REGLAN IV WITH GOOOD EFFECT.\nPLAN: WEAN OFF LEVO, REMOVE IABP LATER THIS AM IF NUMBERS REMAIN GOOD. ?TRANSFER TO FLOOR IN AFTRNOON IF STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-08 00:00:00.000", "description": "Report", "row_id": 1563281, "text": "CSRU PRogress Note\nS/O: Neuro: Comf after toradol and tylenol 3. ALert and oriented.\n CV: Levo off, IABP dcd. CO 7. SG and cordis dcd. IV amio .5.\n Resp: Prod cough, sao2 98% on 3lnp.\n Renal: UO 45/hr. Wt up 12 kg.\n Heme: Cts serosang. On aspirin.\n ID: Afebrile, on vanco.\n GI: Zofran before turning, no further nausea. Tol cl liqs.On zantac.\n ENdo: Insulin protocol, glu now 135.\n Skin: INtact.\n Lines: 2 periphs.\n Family: In to visit.\nA: Stable postop course.\nP: Turn after 1600. Ready for transfer to floor if bed available later. ?diurese.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-08 00:00:00.000", "description": "Report", "row_id": 1563282, "text": "Shift Note\nPt is neurologically intact, MAE to command. Hemodynamics as per flowsheet. Lungs are CTA but diminished. Pt c/o nausea, Tx with zofran with effect. IABP site is CD+I. Pt able to sit up in bed. See flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2131-06-09 00:00:00.000", "description": "Report", "row_id": 1563283, "text": "D Pt A+O VSS. Lungs rhonchorus but clear after coughing. Patients on 3l NC sat >95. Amiodarone at .5mg. Foley to C/D. RT Leg dsg noted to have bloody staining at inner thigh area about 2x3 at 24:00.D/P andP/T pules palp but weak.\nA patient stable . bleeding noted from graft site.\nR rt leg dsg changed. lower leg with steri strips clean and dry. Thigh very eccymotic. A two inch area at the thigh oozing blood steri strips off some clotting at site noted . Reapplied steristrips, DSD, and Ace . at present dsg D/I.\nP monitor rt leg for further bleeding.\n" }, { "category": "ECG", "chartdate": "2131-06-05 00:00:00.000", "description": "Report", "row_id": 176704, "text": "Sinus rhythm. Right bundle-branch block. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2181-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 758234, "text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumia, cause of dyspnea\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with\n REASON FOR THIS EXAMINATION:\n ? pneumia, cause of dyspnea\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: None\n\n AP UPRIGHT PORTABLE CHEST: There is a very large right-sided pleural effusion\n +/- pleural thickening. There is volume loss of the right lower lung\n particularly. There is no shift of the mediastinum either toward or away.\n There may be a small left-sided pleural effusion and there is left lower lobe\n atelectasis. The remainder of the left lung is clear and the pulmonary\n vascularity is within normal limits. In addition, there is apparent narrowing\n of the left main stem bronchus by soft tissue attenuation. The hilar contours\n are difficult to assess.\n\n IMPRESSION: Large right-sided pleural effusion with possible mediastinal\n adenopathy. Correlation with CT is recommended either prior to or after\n drainage of the right-sided effusion.\n\n" }, { "category": "Radiology", "chartdate": "2181-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 758311, "text": " 10:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post chest tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with\n REASON FOR THIS EXAMINATION:\n post chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Re-assess right pleural effusion status post chest tube placement.\n\n COMPARISONS: \n\n AP CHEST: In the interval since the prior study, a right chest tube has been\n placed and the tip is located adjacent to the right hilum. There is marked\n improvement in the right pleural effusion, however, there is now a moderate\n pneumothorax, which is greater towards the base, with associated collapse of\n the right middle and lower lobe. There is expansion of the right upper lobe\n when compared to the prior study.\n\n There is extensive mediastinal lymphadenopathy bilaterally which is likely\n associated with underlying neoplasm. A small left pleural effusion with\n patchy left lower lobe atelectasis is also noted. The pulmonary vasculature is\n within normal limits.\n\n IMPRESSION: 1) Moderate right pneumothorax status post drainage of right\n pleural effusion via chest tube. There is collapse of the right middle and\n right lower lobes. Findings were discussed with the house officer caring for\n the patient at approximately 11:30 A.M. on .\n 2) Extensive mediastinal lymphadenopathy which is highly concerning for\n bronchogenic carcinoma, lymphoma or metastatic disease. TB is\n considered less likely. Apparent right hilar mass, which may be responsible\n for the presence of middle and lower lobe collapse.\n 3) Small pleural effusion on the left with mild associated atelectasis.\n\n" }, { "category": "Echo", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 71413, "text": "PATIENT/TEST INFORMATION:\nIndication: ?Pericardial effusion. Tamponade (drained )\nHeight: (in) 64\nWeight (lb): 112\nBSA (m2): 1.53 m2\nBP (mm Hg): 112/56\nStatus: Inpatient\nDate/Time: at 14:23\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) pulmonic regurgitation\nis seen.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Septal hypokinesis is present.\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened.\n4. There is a small pericardial effusion with fibrin deposits on the surface\nof the heart.. There are no echocardiographic signs of tamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 176889, "text": "Probable sinus tachycardia with short P-R interval. Compared to the previous\ntracing of atrial premature beats are not seen and the bsaeline rate is\nfaster. No new acute ST-T wave changes.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 176890, "text": "Sinus tachycardia\n- supraventricular extrasystoles\nShort PR interval\nNondiagnostic T wave changes\nSince previous tracing, normal sinus rhythm restored\n\n" }, { "category": "ECG", "chartdate": "2181-05-22 00:00:00.000", "description": "Report", "row_id": 176891, "text": "Atrial fibrillation with uncontrolled ventricular response\nExtensive ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rate/rhythm\nLow voltage\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2181-05-24 00:00:00.000", "description": "Report", "row_id": 176658, "text": "Sinus rhythm with freuent atrial ectopy. Short P-R interval. ST segment coving\nin leads V2-V3 with J point elevation in lead V5. Compared to the previous\ntracing atrial fibrillation is no longer seen and anterolateral ST segment\nchanges are new. Rule out ischemia.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 176659, "text": "Atrial fibrillation with a rapid ventricular response of about 168. Diffuse\nST-T wave changes are probably due to the rapid rate. Compared to the previous\ntracing atrial fibrillation is new.\nTRACING #2\n\n" }, { "category": "Nursing/other", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 1450259, "text": "MICU nursing narrative note 7p-7a\nThis is a 50 yr old patient transferred from hospital presenting there on with SOB. Cont. to do poorly and was seen by PCP with /o dysphagia and Edynophagia. So she was started on protonix, reasons for possibly irritating esophagus with continuous coughing over the past month. Then over last 5 days SOB increased, noted by PCP to have decreased BS on R side and sent to ED. Had a thoracentesis where they removed 1300cc of exadative fluid. CT revealed mediastinal adenopathy with narrowing of R main pulm artery and RLL bronchus as well as bilateral pleural nodules. CT scan also revealed numerous lesions on liver. Moved to ICU due to numerous occasions of SVT/Afib. ECHO revealed moderate size pericaaardial effusion and early evidence of tamponade. Then transferred to for drainage of pericardial effusion, drained off approx 250-300cc cloudy yellow fluid.\n\nAllergic to Sulfa.\n\nNeuro: AAOx3, MAE, although slightly weak. Answers questions approp and can talk extensively without becoming SOB.\n\nCV: SR 90's with no ectopy at present, but did experience many occasions of SVT with rates into 170's highest, did not sustain this high for long. Started on metoprolol at 12.5mg po with notable results. Pt also stated that she could \"feel my heart race\" during these episodes and that after taking the \"pill\" has not experienced this \"racing\" experience. mg level last HS 1.6 and repleted with 2gms mgso4 times one dose. WBC 12 started on ABX last HS ceftriaxone and Levaquin. Platelest last HS 500's, now this am down to 67?? Has one peripheral IV L hand, difficult to draw blood from, but has good veins LAC where blood drawn from.\n\nResp: RR 20's, remains c/o slight difficulty with taking deep breaths, although on observation during rest times, appears to be taking good deep even breaths. sats 96-97% on N/C 6L. Lungs coarse to crackles RUL/RLL.\n\nGI: NPO at present. Although does take PO meds and states that does have difficulty occas with swallowing pills and occasionally has to eat a cracker to help med go down.\n\nGU: Foley present draining amber clear urine. approx 30-50cc/hr.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 1450260, "text": "Addendum to above note:\nCV: pericardial drain in place and attached to drain bag, with clear/pink tinged with white string fragments noted in tubing, very minimal fluid in tubing and almost none at all in bag. aspirating and Flushing tubing every 4hr with 2cc of 10u/ml heparin/2cc NS.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-23 00:00:00.000", "description": "Report", "row_id": 1450261, "text": "Nursing Progress Note.\nCV: Pt received this am in a NSR/sinus tach and a low grade temp. Tmax 99.5 @ noontime. Pt reports no overt CP, but does have chest pain assoc c end expiration which she has some difficulty describing but feels that the pain is more attributable to her lungs than to her heart. Pt developed multiple runs of this am beginning around 11:00. During pt denied feeling dizzy or lightheaded. Multiple EKG's have been obtained today including a run -- all EKG's provided to team for close analysis. Pt Metoprolol dose subsequently increased to 25mg Q12 hrs c first dose admin @ 11:00 (original dose = 12.5mg Q12 hrs). Pt has + freq PAC's as well. Good peripheral pulses, no hematoma assoc c R Femoral sheath site. Pericardial drain in place and has drained approx 200ml yellow cloudy drainage since :00, team aware. Cont to flush Pericardial drain Q4 hrs c 2ml of 10unit/ml heparin solution. AM lytes and hematology labs WNL. Echocardiogram to be performed at BS this afternoon. Pneumoboots in place.\nMS: Pt c/o end expiration pleuritic CP rated this am. Med c 1mg IV MSO4 c good temp affect noted. Pt also coached on deep breathing exercises by RT c + affect as well. Pt presently c minimal pain and declined further doses of PRN MSO4. Pt cooperative, pleasant, cooperative, MAE. Pt appears weak, pale and fatigued.\nRESP: Pt on 6LNCO2 c Sats in the mid 90's. Diminished BS noted on R side, L side clear c some coarse BS appreciated. No cough. RR in teens.\nGU: Low UO noted today c 10-30ml output/hr since :00. Team notified and IV hydration changed from D51/2NS @ 75ml/hr to NS @ 125ml/hr. Urine is amber colored and clear. Pt presently net + of 400ml since admit to MICU. Foley in place.\nFAMILY: Husband presently visiting @ BS and kept up-to-date c POC/pt status. The pt is a full code.\nOTHER: Please see CareWeb for additional pt care data/comments.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-24 00:00:00.000", "description": "Report", "row_id": 1450262, "text": "7p to 7a Micu Progress Note\n\nPt underwent right neck lymph node bx last eve. Performed in the OR under local anesthesia - results + malignancy, poorly differentiated cells md. Plan is for Onc consult this am.\n\nResp - Pt initially managed on 6lnc with sats 94-96%. c/o increasing sob and face tent added with sats increasing to 97-100%. RR remained 24-30 throughout the noc. Lung sounds diminished on the right and coarse on the left. Brief episode of wheezing which resolved after albuterol neb given. ? thoracentesis if sob persists.\n\nC-V - HR 88-115 SR -St until 5 am when pt experienced fleeting episodes of SVT and then appeared to be in afib. Ekg taken and given to md. ? paf vs SR with freq pac's. Bp stable throughout . SBP 110-130. Pt asx - slept through arrhythmias. Had received 25 mg po lopressor at mn. Pericardial drain flushed q 4hrs with heparin. Drained 130 ccs pink fluid.\n\nNeuro - Slept intermittently. Understandably very anxious after being told bx + for malignancy. Sedated with 1 mg morphine iv x 2 for pleuritic cp with good effect. Also treated with 1 mg ativan iv and 1 mg po ativan for anxiety. Arouses easily to verbal stimuli. A+o x 3.\n\nID - Max temp 100.2 po. Antibiotics for post -obstructive pneum consist of levoflox and ceftriaxone.\n\nGI - Remains NPO x for sips with meds. Difficulty swallowing pills. Abd soft. +BS. No stool. Passing flatus.\n\nF/E - TFB + 1400 yest. IV NS infusing at 125ccs/hr. U/o 20-25 ccs/hr via foley cath.\n\nSkin - Neck bx dssg d+i. Left arm edematous from axilla to hand - ? secondary to lymph node dz.\n\nAccess - #22 left hand.\n\nSocial - Husband stayed with pt throughout the eve. Informed of bx results by surgeon. Declined to stay overnight. Husband later called and was updated on pts condition by R.N. He will return in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-05-24 00:00:00.000", "description": "Report", "row_id": 1450263, "text": "FOCUS; NURSING PROGRESS NOTE.\nREVEIW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X3. COOPERATIVE WITH CARE.\nRESP- ON 5L NC AND 70% HUMIDIFIED FM THIS AM WITH SATS IN THE MID 90'S. MASK REMOVED AND KEPT AT BEDSIDE. SATS IN MID 90'S. RESP 18-27. RIGHT CT PLACED BY DR . DRAINED 2000CC SEROSANG DRAINAGE. HAS SMALL AIR LEAK. GOOD FLUCTUATION. NO CREPITUS. BS COARSE ON THE LEFT. DIMINISHED ON THE RIGHT.\nCARDIAC- HR 115 ST TO 98 SR ON LOPRESSOR 25MG . SBP 106-136.\nGI- ABD SOFT WITH POS BS. NO STOOL. REMAINS NPO EXCEPT MEDS. ON NS AT 125CC/HR.\nGU- UO VIA FOLEY CATH 25-45CC/HR.\nSKIN- SKIN INTACT.\nID- WBC 16.3. CONTINUES ON LEVOFLOXACIN. CEFTRIAXONE DC'D.\nONC- ONC FELLOW BY TO SEE PATIENT THIS AM. ONC IS TO REVIEW PATIENT'S DATA AND THEN RETURN WITH A PLAN OF CARE.\n HUSBAND IN TO VISIT. HE WAS UPDATED ON THE PATIENT'S CONDITION. MOTHER CALLED AND SPOKE TO HER DAUGHTER.\nDISPO- REMAINS IN THE MICU A FULL CODE. AWAITING ONCOLOGIES INPUT.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-24 00:00:00.000", "description": "Report", "row_id": 1450264, "text": "focus; addendum\ncardiac- hr up to 121. lopressor dose increased to 25mg tid and 250cc ns bolus ordered and given. hr down to 110.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-25 00:00:00.000", "description": "Report", "row_id": 1450269, "text": "FOCUS; ADDENDUM\nSOCIAL- FAMILY MEEETING HELD WITH ONCOLOGY SERVICE. FINAL PATH NOT BACK YET. WILL BE BACK MONDAY. ONCOLOGIST SPOKE OF OPTIONS OF STENT PLACEMENT AS PALLATIVE MEASURE TO TREAT SOB. ALSO DISCUSSED CHEMO OPTION AS WELL AS PALLATIVE CHEMO. ALSO PATIENT'S WISHES FOR INTUBATION DISCUSSED. DR ALSO PRESENT TO DISCUSS STENT PLACEMENT AS PALLATIVE TREATMENT FOR PATIENT'S DISEASE PROCESS. PATIENT DECIDED TO HAVE STENT PLACEMENT DONE. CONSENT FOR OR SIGNED AS WELL AS FOR ANESTHESIA. PATIENT TRANSPORTED TO OR BY ANESTHESIA. FAMILY AND PATIENT TO DISCUSS OTHER ISSUES REGARDING PLAN OF CARE. AT PRESENT PATIENT IS LEANING TOWARD GOING HOME WITH THE AIDE OF HOPICE. FAMILY TO CONTINUE THEIR DISCUSSION AFTER PATIENT IS RECOVERED FROM HER STENT PLACEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-25 00:00:00.000", "description": "Report", "row_id": 1450270, "text": "FOCUS; ADDENDUM\nD. PATIENT RETURNED FROM OR 1815 S/P STENT IN RIGHT AND LEFT. HR IN THE 130'S ST WITH SATS 83%. ANESTHESIA AND DR ACCOMPANYING PATIENT. PATIENT LETHARGIC BUT AROUSABLE. PLACED ON MASK VENT 100% FIO2 WITH 5 PEEP AND 5 PS. SATS UP TO 96%. HR DOWN TO THE 120'S. LEFT RADIAL ALINE PLACED IN OR TRANSDUCED WITH BP 120'S OVER 70'S.\nA. REQUIRING MASK VENTILATION AT PRESENT TILL IS AWAKE ENOUGH TO BREATHON HER OWN.\nR. CONTINUE MASK VENT.\nP. CHECK ABG AND WEAN TO NP AS TOLERATED\n" }, { "category": "Nursing/other", "chartdate": "2181-05-25 00:00:00.000", "description": "Report", "row_id": 1450271, "text": " PTis awake and orinted to time and place CPAP Mask has been discoun, 5Lpm N/C in place O2 sat is 93% BS Rhonchia with some end exp-Wheexing 2.5 mg Albuterol Neb isgeving Bs improved, some cought but not strong enght to be productive.\nwill count to monitor .\n" }, { "category": "Nursing/other", "chartdate": "2181-05-25 00:00:00.000", "description": "Report", "row_id": 1450272, "text": "Pt still expe some SOB BS end exp Wheeze Albuterol is HR 113 RR 17 she seem to be some what ressles but coop.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-26 00:00:00.000", "description": "Report", "row_id": 1450273, "text": "PT is DNR she is having a truble breathing, decreased Bs Rhonchai exp wheezing poor cough and unproductive. Albuterol Neb TX X4 were giving last night and this morning with very littel effact.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-26 00:00:00.000", "description": "Report", "row_id": 1450274, "text": "MICU NPN 7pm-7am\nPt's resp. status started again to deteriorate early in the evening. Dr. in to speak with pt. and spoke again with husband. Decision made to keep pt. comfortable, and medicate as needed with ativan and morphine.\n\nNeuro: Pt. initially very alert and responsive. Medicated with 2mg iv morphine and 2mg iv ativan as needed for discomfort and anxiety. Pt. stated that \"all she wanted to do is sleep\". Pt. allowed to sleep most of the night.\n\nResp: Received on masked ventilation, abg was good, and pt. asking that mask be removed, therefore per Dr. , pt. placed initially on 5L NC, shortly after became more tachypnic and sat's began to decrease into the 80's. Bilateral exp. wheezes heard throughout. Dr. aware. %0% face tent, then 70% face tent placed on pt. without much improvement. Medicated with 2mg iv morphine and treated with neb. Later pt. took off mask because it made her uncomfotable. Informed her that her oxygenation would drop without additional O2 and pt. stated that she understood, but was not comfortable with mask. R chest tube draining serous fluid.\n\nCV: BP stable, sinus rhythm- sinus tachycardia with occ pac's. Pericardial drain in draining 30cc of serous fluid. Continues to have drain flushed q4 as ordered.\n\nGI: NpO, pt. very SOB, and only taking small sips of water and ice chips. Po meds held, Dr. and aware.\n\nGU: voiding scant amounts of cloudy urine via foley.\n\nSKIN: total anasarca, ivf decreased to kvo due to increased swelling in arms and feet, also due to 4am lung sounds very coarse with crackles on left and pt's c/o difficulty breathing.\n\nPLAN: pt. made , discuss further withdrawl of care options with family in am. Husband is appropriately upset, and very supportive for pt. Pt's very good friends in to visit with her last night and said bye.\n\nSee carevue for further data.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-26 00:00:00.000", "description": "Report", "row_id": 1450275, "text": "NPN 7a-7p\n\nReview of Systems:\n\nNeuro: Pt. received A+O X 3; lethargic and SOB. Following commands and interactive. More lethargic as the shift progressed. About 1400, pt. noteably more SOB and less arousable. Pt. denying pain throughout shift. About 1600, pt. appearing agonal. MSO4 gtt initiated at that time; 0.5mg/hr and increased to 2.0mg/hr with 1.0 and 2.0 mg boluses. Pt. also receiving Ativan TID. Plan- awaiting arrival of husband and son; will increase MSO4 gtt to titrate to comfort.\n\nResp: Received on 5L NC; sat's 88-92%. Pt. requesting FM (70%) mid morning for SOB and has been wearing FM throughout the shift. Now at 100% with 6LNC to maintain oz sat's >90%. LS- coarse throughout with right decreased base at CT site. Exp. wheezing noted throughout the shift and has received Alb. nebs. LS worsening about 1400; NT sx'd after explaining pallative efforts to pt.; pt. without gag, nor cough; sx'd for no sputum...? cardiac in origin. Pt. currently less responsive and has not reported SOB since MSO4 intiated.\n\nCV: HR Sinus Tach with burst of SVT just prior to sx'ing rate to 200. Receving Lopressor 5mg IVP q 6 hours. BP tolerating sedatatives and lopressor. Pt. remains on IVF at 75cc/hr D5NS. + pulses.\n\nGI: ABD distended, minimal movement heard. Taking sips of coffee, gingerale this am when more responsive. No BM.\n\nGU: U/O minimal; yellow, cloudy.\n\nID: Afebrile. ABx. d/c'd.\n\nSocial: D/t status worsening, husband called (husband left for home about 11am, ) and asked to come back in. Husband and son due in anytime. Protestant religious person contact and due in about 6pm. Will cont. emotional support for family and pt. Also, of note, N.P CNS contact as resource for pallative care management of pt.; due in tom'row to more formerly consult on pt. suggesting inhaled MSO4 if current regimen does not aide in relieving SOB.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-27 00:00:00.000", "description": "Report", "row_id": 1450276, "text": "MICU NPN 7pm-7am\nPt. remains on morphine. As night progressed she had periods of increased work of breathing assoc. with wheezing and grunting. Morphine gtt titrated up to 30mg/hr. Pt. NOW appears comfortable. Husband at the beside all night. This am the husband is much more withdrawn and more emotional. SUpport provided to him, and encouraged him to talk to her.\nIVF decreased to kvo due to increased swelling in her extremeties and decreased urine output.\nSee carevue for further data.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-27 00:00:00.000", "description": "Report", "row_id": 1450277, "text": "Pt. received on 30mg of MSO4; appearing comfortable. O2 turned off with respect given to husband and pt. wishes; pt. passed on within 30 minutes of d/c of O2; Dr. called and pronounced pt. at 11:40am. Pupils fixed and dilated, no pulse, pt. apenic. Family is discussing option of an autopsy. Husband remained at bedside.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-05-24 00:00:00.000", "description": "Report", "row_id": 1450265, "text": "focus; addendum\nsocial- patient's wedding band and diamond removed and given to husband to take home.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-24 00:00:00.000", "description": "Report", "row_id": 1450266, "text": "FOCUS; ADDENDUM\nDISPO- ? IF PATIENT BE TRANSFERRED TO FIRM TOMMORROW SO SHE CAN RECEIVE HER CHEMO FROM THE 4 SOUTH NURSES. BED FACILITATOR INFORMED OF THIS. SHE WILL LET 4 AND 4 SOUTH KNOW OF THESE POTENTIAL PLANS.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-25 00:00:00.000", "description": "Report", "row_id": 1450267, "text": "7p to 7a Micu Progress Note\n\nNeuro - pt remains a+o x 3. Medicated with ativan x 1 to help with sleep and mso4 x 2 for pain from ct insertion site. Slept most of the noc.\n\nResp - 02 sats 93-94% on 5lnc. Pt did not utilize humidified FM at all. Lungs sounds remain diminished on the right and coarse on the left. CT draining approx 750 ccs serosanguinous fluid. No crepitus. Dssg d+i.\n\nC-V - HR 98-124 SR -ST. Occas PACs. No episode of SVT noted. SBP 100-130. Rx with lopressor 25mg po tid. Pericardial drainage decreasing in quantity. Drain flushed q 4hrs with heparin.\n\nGI - NPO except meds. Abd soft. +BS. No stool.\n\nF/E - TFB + 300 yest. IVF 125cc/hr. U/o approx 30cc/hr.\n\nID - Max temp 98.8 po. CBC pend. Only antibiotic pt is receiving is levoflox.\n\nSocial - No phone calls or visits this shift.\n\nPlan is for ? abd ct today to r/o retroperitoneal nodes. ? transfer to onc unit to initiate chemo.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-05-25 00:00:00.000", "description": "Report", "row_id": 1450268, "text": "FOCUS; NURSING PROGRESS NOTE.\nMRS A 50 YEAR OLD FEMALE ADMITTED TO ON WITH SOB. SHE HAD A FEW WEEK HX OF NOT FEELING WELL. HAD SOB AND DYSPHAGIA AND WAS BEING TX WITH ANTIBIODICS AND PROTONIX BY HER PCP FOR THIS. SHE WAS SEEN BY HER PCP AND HAD DIMINISHED BS ON THE RIGHT. SENT TO ER AT . A CT SHOWED MEDIASTINAL ADENOPATHY AND PULM NODUALES. A THORACENTESIS DONE REMOVED 1300CC OF EXUDATIVE MATERIAL. SHE WAS TRANSFERRED TO THE ICU THERE FOR BOUTS OF SVT AND AFIB. AN ECHO DONE SHOWED A MODERATE SIZE PERICARDIAL EFFUSION. SHE HAD EARLY EVIDENCE OF CARDIAC TAMPONADE. SHE WAS TRANSFERRED TO THE ON PERICARDIAL DRAIN ON . DRAIN PLACED AND DRAINED 250-300CC OF CLOUDY YELLOW FLUID. ON EVEINING OF SHE ALSO HAD A RIGHT NECK LYMPH NODE BIOPSY THAT WS POS FOR A MALIGNANCY OF POORLY DIFFERENTIATED CELLS.\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X3 AND MOST COOPERATIVE WITH CARE.\nRESP- ON 5L NC WITH SATS OF 93% OR GREATER. SHE LIKES TO HAVE A 70% FM ON HER BED IN CASE SHE FEELS SOB. SHE USES THIS PERIODICALLY. SHE HAS A RIGHT PLEURAL CT THAT IS DRAINING SEROUS DRAINAGE. THIS DRAINED 750CC TODAY. BS COARSE ON THE LEFT. ON THE RIGHT CLEAR UPPER AND DIMINISHED LOWER.\nCARDIAC- HR 100-116. ON LOPRESSOR 25MG TID. HAS PERICARDIAL DRAIN IN PLACE DRAINING SMALL AMOUNTS SEROUS DRAINAGE. DRAIN ASPIRATED Q 4HOURS AND FLUSHED WITH 2 CC OF 1;10U/CC OF HEPARIN. SBP ABOVE 100.\nGI- ABD SOFT WITH POS BS.\nGU- FOLEY IN PLACE DRAINING CLOUDY YELLOW URINE.\nSKIN- INTACT.\n SUPPORTIVE HUSBAND AND 25YEAR OLD SON.\nPLAN- AWAITING DISCUSSION BETWEEN ONCOLOGY AND PATIENT AND DISCUSSION OF CODE STATUS. ? TRANSFER TO EAST MICU IF CHEMO IS AN OPTION.\n" } ]

[ { "category": "Respiratory ", "chartdate": "2187-07-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685419, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 10 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient admitted to unit from OR. Placed on mechanical ventilation, all\n settings documented on flowsheet.\n" }, { "category": "Nursing", "chartdate": "2187-07-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685414, "text": "Gastrointestinal bleed, other (GI Bleed, GIB), s/p subtotal gastrectomy\n Assessment:\n Arrived from o.r. at 0715 s/p subtotal gastrectomy. Post-op dressing\n cl/d/I, no drainage. J-tube clamped. NGT to low wall suctioned,\n draining dark red blood, approx 150cc\ns thus far. Mechanically\n intubated, sedated with ppf. Hct 35, mag 1.4, ionized ca 1.06.\n Action:\n Calcium and mag repleted. LR continues at 150cc\ns/hr. IV flagyl and\n cefazolin as ordered. Fi02 weaned to 50%.\n Response:\n Repeat labs: mag 1.9, ionizec ca 1.10, hct 31.\n Plan:\n Do no manipulate ngt, monitor output. J-tube to remain clamped.\n Replete lytes prn, continue to monitor hct. Cefazolin and flagyl x\n more doses. Wean vent. as tolerated.\n Hypotension (not Shock)/tachycardia\n Assessment:\n Pt noted to be tachycardic to the 130\ns (sinus) this morning, sbp\n dipping to 80\ns. u/o 10cc\ns for one hour. Also pt becomes\n hypotensive to sbp 70\ns with turning/repositioning but recovers quickly\n without interventions\n Action:\n Discussed with icu team/attending -> pt received total 1250cc\ns ns in\n boluses.\n Response:\n u/o improved to 60-80cc\ns hr. HR decreased to 100\ns, sbp improved to\n 110\n Plan:\n Continue fluid recusitation as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt tachycardic to 130\ns and hypertensive to 150\ns briefly this morning.\n PPF gtt infusing.\n Action:\n Fentynal gtt initiated.\n Response:\n HR improved to 100\ns, sbp to 110\n Plan:\n Continue fentynal gtt and titrate as necessary.\n" }, { "category": "Nursing", "chartdate": "2187-07-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685418, "text": "Gastrointestinal bleed, other (GI Bleed, GIB), s/p subtotal gastrectomy\n Assessment:\n Arrived from o.r. at 0715 s/p subtotal gastrectomy. Post-op dressing\n cl/d/I, no drainage. J-tube clamped. NGT to low wall suctioned,\n draining dark red blood, approx 150cc\ns thus far. Mechanically\n intubated, sedated with ppf. Hct 35, mag 1.4, ionized ca 1.06.\n Action:\n Calcium and mag repleted. LR continues at 150cc\ns/hr. IV flagyl and\n cefazolin as ordered. Fi02 weaned to 50%.\n Response:\n Repeat labs: mag 1.9, ionizec ca 1.10, hct 31.\n Plan:\n Do no manipulate ngt, monitor output. J-tube to remain clamped.\n Replete lytes prn, continue to monitor hct. Cefazolin and flagyl x\n more doses. Wean vent. as tolerated.\n Hypotension (not Shock)/tachycardia\n Assessment:\n Pt noted to be tachycardic to the 130\ns (sinus) this morning, sbp\n dipping to 80\ns. u/o 10cc\ns for one hour. Also pt becomes\n hypotensive to sbp 70\ns with turning/repositioning but recovers quickly\n without interventions\n Action:\n Discussed with icu team/attending -> pt received total 1250cc\ns ns in\n boluses.\n Response:\n u/o improved to 60-80cc\ns hr. HR decreased to 100\ns, sbp improved to\n 110\n Plan:\n Continue fluid resuscitation as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt tachycardic to 130\ns and hypertensive to 150\ns briefly this\n morning. PPF gtt infusing.\n Action:\n Fentynal gtt initiated.\n Response:\n HR improved to 100\ns, sbp to 110\n Plan:\n Continue fentynal gtt and titrate as necessary.\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Dr. spoke with family this morning after surgery and informed the\n family of patient\ns poor prognosis (life expectancy < 6 months.)\n Action:\n S.w. consulted, emotional support provided.\n Response:\n Family distraught, but appears to be coping adequately.\n Plan:\n Continue social work involvement as needed, continue emotional support\n and education.\n" }, { "category": "Nursing", "chartdate": "2187-07-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685305, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt arrived from floor s/p CODE BLE called after pt vomited large amt\n frank red blood, became acutely tachycardic and hypotensive but\n remained responsive. Received by this RN at 2300. ST 140-150\ns. Not\n requiring pressors. Initial SBP 140-150 but decreasing to ~100 prior\n to transfusions. Pt alert and oriented x 3.\n Action:\n NGT placed by MD\n Right IJ triple introducer placed\n placement confirmed by CXR\n 3 units PRBC up\n 3 liters LR up\n 1 unit FFP up\n Wife updated by MICU and surgery resident\n Response:\n 900 cc bright red blood out of NGT\n SBP 140 after fluid/product\n HR down to 120\n Pt shivering from fluid\n wrapped in warm blankets\n Wife to bedside\n Plan:\n Sent emergently to OR in care of anesthesia at 2400. Family given\n beeper by this RN. Wife updated by this RN after OR contact for\n brief update. ETA 0700.\n" }, { "category": "Nursing", "chartdate": "2187-07-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685477, "text": "S/P Subtotal Gastrectomy\n Assessment:\n Stable overnight\n Action:\n Pt remained intubated overnight thus sedated on Propofol.Despite\n PPV=,CVP= , HUO = 40-70ml . IVF infusing at 150ml/hr. NG\n aspirate old blood to currently bilious. Abd incision D & I.\n Response:\n Pt slightly restless off Propofol,moves all extremites but does not\n follow commands. Pt sleeps on Propofol 75mcq/hr.\n Plan:\n Wean to extubate,\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt appeared pain free overnite on Fentanyl 100mcq/hr\n Action:\n No change in dose overnite\n Response:\n VS stable\n Plan:\n Maintain same dose. Monitor pt for increase of pain when pt more\n active.\n Hypotension (not Shock)\n Assessment:\n BP stable overnight\n Action:\n IVF remained at 150ml/hr . Await am Hct\n Response:\n Adaquete urine output\n Plan:\n Check am labs. Monitor for S&S for bleeding\n" }, { "category": "Respiratory ", "chartdate": "2187-07-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685642, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: White / Tenacious\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation, Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot manage secretions, Hemodynimic\n instability\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2187-07-29 00:00:00.000", "description": "Intensivist Note", "row_id": 685651, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Chief complaint:\n nausea\n PMHx:\n HTN, DMII, COPD with home O2, smoker\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS\n Continuous at 75 ml/hr12. Phenylephrine 0.5-3 mcg/kg/min IV DRIP\n TITRATE TO MAPS >60 Order date: @ 0329\n 4. Acetylcysteine 20% 3-5 mL NEB Q6H:PRN thick secretions 13.\n Potassium Chloride IV Sliding Scale 07/03\n 5. Calcium Gluconate IV Sliding Scale Order , Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale, Magnesium Sulfate IV Sliding Scale , Propofol\n 20-100 mcg/kg/min IV DRIP TITRATE TO sedation, Famotidine 20 mg IV\n Q12H , Sodium Phosphate IV Sliding Scale , Fentanyl Citrate 25-100\n mcg IV Q4H:PRN pain , Fentanyl Citrate 100-200 mcg/hr IV DRIP\n INFUSION\n 24 Hour Events:\n TRIPLE INTRODUCER - STOP 11:39 AM\n MULTI LUMEN - START 11:43 AM\n Tolerated CPAP w/ PS for several hours but became hypercarbic and\n acidotic with copius secretions. PLaced back on CMV airway peak\n pressures to the 40's. Responded to albuterol and suctioning.\n Post operative day:\n POD#2 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:21 AM\n Metronidazole - 06:05 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.7\nC (99.9\n HR: 95 (95 - 108) bpm\n BP: 98/54(68) {88/45(58) - 140/76(96)} mmHg\n RR: 20 (14 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.4 kg (admission): 89.4 kg\n CVP: 14 (8 - 20) mmHg\n Total In:\n 4,409 mL\n 623 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,379 mL\n 623 mL\n Blood products:\n Total out:\n 2,680 mL\n 670 mL\n Urine:\n 2,610 mL\n 670 mL\n NG:\n 70 mL\n Stool:\n Drains:\n Balance:\n 1,729 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 481 (399 - 505) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 41 cmH2O\n Plateau: 26 cmH2O\n Compliance: 41.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.25/76./96./32/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilat, Diminished: bilat), wet sounding\n Abdominal: Soft, dressing CDI\n Neurologic: Sedated\n Labs / Radiology\n 221 K/uL\n 8.9 g/dL\n 127 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 7 mg/dL\n 105 mEq/L\n 139 mEq/L\n 25.9 %\n 18.3 K/uL\n [image002.jpg]\n 06:05 AM\n 07:36 AM\n 07:50 AM\n 02:08 PM\n 02:34 PM\n 11:58 PM\n 01:54 AM\n 03:31 AM\n 01:46 AM\n 02:03 AM\n WBC\n 30.1\n 23.3\n 17.8\n 18.3\n Hct\n 35\n 35.3\n 31.2\n 27.8\n 25.9\n Plt\n 21\n Creatinine\n 0.8\n 0.8\n 0.6\n 0.5\n TCO2\n 26\n 26\n 27\n 28\n 28\n 35\n Glucose\n 118\n 136\n 145\n 118\n 127\n Other labs: PT / PTT / INR:14.1/26.1/1.2, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:, Alk-Phos / T bili:30/0.4, Amylase /\n Lipase:48/, Lactic Acid:1.6 mmol/L, Albumin:2.3 g/dL, LDH:132 IU/L,\n Ca:7.3 mg/dL, Mg:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 53M with gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II, intubated in ICU, failed vent\n wean \n Neurologic: Propofol for sedation Fentanyl for pain\n Cardiovascular: Not on pressors. Became transiently hypotensive with\n turns + suction. MAP>60, phenylephrine dripordered if needed\n Pulmonary: Cont ETT, Tolerated CPAP w/ PS for several hours but became\n hypercarbic and acidotic with copius secretions. PLaced back on CMV\n airway peak pressures to the 40's. Responded to albuterol and\n suctioning, plan to try PSV again. CXR ordered. Decrease FI02 to 50\n Gastrointestinal / Abdomen: Capped JT, NPO\n Nutrition: D5 + 20meq K@75 . Begin TF today.\n Renal: pt w/ good U/O (100-300/hr) but remains largely net positive.\n Begin diuresis.\n Hematology: following HCT\n Endocrine: RISS, RISS\n Infectious Disease: Kefzol/flagyl x 3 doses. Stomach was not\n perforated Sputum culture sent.\n Lines / Tubes / Drains: NG to suction, JT, RIJ, Aline\n Wounds: abd wounds dressing C/D/I\n Imaging: CXR today, F/U today's CXR\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:25 AM\n 20 Gauge - 11:30 AM\n Multi Lumen - 11:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 min\n" }, { "category": "Nutrition", "chartdate": "2187-07-30 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 685814, "text": "Subjective:\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 85 kg\n 24 (based on usual wt)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 102% based on usual body wt\n 71.8kg\n 118%\n Diagnosis: Upper GIB\n PMH : HTN, DM type 2, COPD with home 02, smoker\n Food allergies and intolerances: no known food allergies\n Pertinent medications: RISS, Famotidine, colace, others noted\n Labs:\n Value\n Date\n Glucose\n 107 mg/dL\n 02:16 AM\n Glucose Finger Stick\n 122\n 10:00 PM\n BUN\n 7 mg/dL\n 02:16 AM\n Creatinine\n 0.5 mg/dL\n 02:16 AM\n Sodium\n 143 mEq/L\n 02:16 AM\n Potassium\n 3.9 mEq/L\n 02:16 AM\n Chloride\n 102 mEq/L\n 02:16 AM\n TCO2\n 33 mEq/L\n 02:16 AM\n PO2 (arterial)\n 67 mm Hg\n 12:29 PM\n PCO2 (arterial)\n 50 mm Hg\n 12:29 PM\n pH (arterial)\n 7.45 units\n 12:29 PM\n CO2 (Calc) arterial\n 36 mEq/L\n 12:29 PM\n Albumin\n 2.3 g/dL\n 11:10 PM\n Calcium non-ionized\n 7.8 mg/dL\n 02:16 AM\n Phosphorus\n 3.4 mg/dL\n 02:16 AM\n Ionized Calcium\n 1.12 mmol/L\n 12:29 PM\n Magnesium\n 1.9 mg/dL\n 02:16 AM\n ALT\n 104 IU/L\n 02:16 AM\n Alkaline Phosphate\n 54 IU/L\n 02:16 AM\n AST\n 53 IU/L\n 02:16 AM\n Amylase\n 48 IU/L\n 11:10 PM\n Total Bilirubin\n 0.4 mg/dL\n 11:10 PM\n WBC\n 12.3 K/uL\n 02:16 AM\n Hgb\n 9.3 g/dL\n 02:16 AM\n Hematocrit\n 27.4 %\n 02:16 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Replete with fiber @ 10cc/hr\n GI: abd soft, hypoactive bowel sounds\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Pt at risk due to: newly dx metastatic cancer, possible tube feed\n dependence\n Estimated Nutritional Needs (based on usual body wt)\n Calories: 1800-2155 ( 25-30 cal/kg)\n Protein: 93-108 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate (trophic tube feeds)\n Specifics:\n 53 y.o. M with newly diagnosed gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II procedure with J-tube placement\n . Patient was extubated , and trophic tube feeds were started\n via J-tube. Patient is tolerating tube feeds so far; will make\n recommendations for tube feeding goal below, which will meet 100% of\n estimated needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Recommend continue with tube feeds via J-tube, advancing\n slowly (10cc q12hrs) to goal of 75cc/hr (1800kcals, 112g protein).\n 2) No residual checks with J-tube; monitor tolerance with abd\n exam and patient complaints.\n 3) Will follow lytes, BG and hydration.\n Please page with any questions. #\n" }, { "category": "Nursing", "chartdate": "2187-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685627, "text": "53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt with NGT in place and to low wall suction. NGT putting out dark\n green bilious fluid. Abdomen is large but soft, hypoactive BS. AM HCT\n 25.9\n Action:\n Discussed HCT with Dr. .\n Response:\n No change. HR remains 90-100 and urine output adequate\n Plan:\n Follow NGT output, monitor HCT levels. Monitor for changes in VS\n Hypotension (not Shock)\n Assessment:\n Pt SBP running 90s-120s while at rest however pt\ns BP noted to drop\n into 70s/30s with suctioning.\n Action:\n Suction pt only as needed\n Response:\n Pt\ns BP recovered back to baseline without intervention\n Plan:\n Follow BP, Keep MAP > 60 . Phenylephrine if MAP falls below 60\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt without signs of pain\n Action:\n Continues on fentanyl drip for pain management\n Response:\n Pt stable\n Plan:\n Monitor pt for signs of pain, continue fentanyl drip for now\n Acidosis, Respiratory\n Assessment:\n ABG showing respiratory acidosis on CPAP with Ph of 7.24 and Co2\n of 76. pt also noted to have large amounts of thick , white secretions.\n PIP up to 48 at times.\n Action:\n Pt put back on CMV mode, 60% fio2-550 X 20 10 PEEP. AM CXR obtained.\n Albuterol and mucomyst PRN\n Response:\n ABG improving slightly in CMV mode (see lab values)\n Plan:\n Continue to follow respiratory status, ABGs, ? bronch today secondary\n to secretions. CXR results pending\n Addendum: Pt\ns SBP lowering into 80s and remaining low. Dr. \n notified. One unit PRBC ordered and hung at 0615. Continue to follow\n HCt and BPs.\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685731, "text": "Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685732, "text": "53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2187-07-30 00:00:00.000", "description": "Intensivist Note", "row_id": 685786, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Chief complaint:\n LGIB\n PMHx:\n PMH: HTN, DMII, COPD with home O2, smoker\n Current medications:\n Acetylcysteine 20% 3-5 mL NEB Q6H:PRN thick secretions, Albuterol\n 0.083% Neb Soln 1 NEB IH Q2H:PRN sob , Calcium Gluconate IV Sliding\n Scale, Docusate Sodium (Liquid) 100 mg PO BID, Famotidine 20 mg IV Q12H\n , Fentanyl Citrate 25-100 mcg IV Q4H:PRN pain , Furosemide 10 mg IV\n ONCE, Insulin SC (per Insulin Flowsheet) Sliding Scale, Ipratropium\n Bromide Neb 1 NEB IH Q2H:PRN sob, Magnesium Sulfate IV Sliding Scale,\n Phenylephrine 0.5-3 mcg/kg/min IV DRIP TITRATE TO MAPS >60, Potassium\n Chloride IV Sliding Scale Order, Sodium Phosphate IV Sliding\n Scale,\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:26 PM\n EXTUBATION - At 02:27 PM\n EXTUBATION - At 02:27 PM\n : Tolerated CPAP w/ PS for several hours but became hypercarbic and\n acidotic with copius secretions. PLaced back on CMV airway peak\n pressures to the 40's. Responded to albuterol and suctioning.\n : lasix given, responded w/ 1L. Extubated. CXR w/ possible RLL PNA\n Post operative day:\n POD#3 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:21 AM\n Metronidazole - 06:05 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:25 PM\n Famotidine (Pepcid) - 07:44 PM\n Fentanyl - 02:12 AM\n Other medications:\n Flowsheet Data as of 04:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.4\n HR: 103 (80 - 121) bpm\n BP: 98/65(76) {88/50(63) - 182/74(99)} mmHg\n RR: 18 (11 - 24) insp/min\n SPO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.5 kg (admission): 89.4 kg\n CVP: 13 (4 - 28) mmHg\n Total In:\n 2,149 mL\n 97 mL\n PO:\n Tube feeding:\n 143 mL\n 43 mL\n IV Fluid:\n 1,738 mL\n 54 mL\n Blood products:\n 248 mL\n Total out:\n 3,945 mL\n 90 mL\n Urine:\n 3,845 mL\n 90 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n -1,796 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 538 (538 - 538) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 24 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 92%\n ABG: 7.38/60/80./33/7\n Ve: 6.6 L/min\n PaO2 / FiO2: 114\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), (Distant heart\n sounds: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , No(t) Wheezes : , No(t) Crackles : , Rhonchorous : ,\n Diminished: bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace, 1+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace, 1+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 268 K/uL\n 9.3 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 102 mEq/L\n 143 mEq/L\n 27.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:54 AM\n 03:31 AM\n 01:46 AM\n 02:03 AM\n 04:41 AM\n 10:27 AM\n 12:54 PM\n 02:09 PM\n 02:16 AM\n 02:39 AM\n WBC\n 17.8\n 18.3\n 12.3\n Hct\n 27.8\n 25.9\n 25.6\n 27.4\n Plt\n 191\n 221\n 268\n Creatinine\n 0.6\n 0.5\n 0.5\n TCO2\n 28\n 35\n 35\n 36\n 37\n 37\n Glucose\n 118\n 127\n 107\n Other labs: PT / PTT / INR:11.9/23.3/1.0, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:104/53, Alk-Phos / T bili:54/0.4, Amylase /\n Lipase:48/, Fibrinogen:591 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.3\n g/dL, LDH:132 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ACIDOSIS, RESPIRATORY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 53M with gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II, intubated in ICU, failed vent\n wean \n Neurologic: Fent for pain control. Start PO pain. PCA. Pain consult.\n Cardiovascular: Not on pressors. Became transiently hypotensive with\n turns + suction. MAP>60, phenylephrine drip ordered if needed\n Pulmonary: Extubated POD2. Pulm toilet. Nebs. Will need OOB. Now w/ RLL\n PNA. Will start vanco, zosyn. Rule out PE w/ CTA of chest.\n Gastrointestinal / Abdomen: NPO w/ trophic TF, Can adv to goal\n Nutrition: Tube feeding, Trophic (10). Will advance.\n Renal: Foley, pt w/ good U/O. Lasix given (1L). Cr 0.5. DC foley\n MN. Will cont w/ diuresis.\n Hematology: Heme: Hct Stable at 27.4. LENI r/o DVT. Team regarding\n SQH.\n Endocrine: RISS\n Infectious Disease: Kefzol/flagyl x 3 doses. Stomach was not\n perforated. WBC 12.3. Will start vanc, zosyn for CAP.\n Lines / Tubes / Drains: Foley, JT, RIJ, Aline, PIV, foley\n Wounds: Dry dressings\n Imaging:\n Fluids: D5 1/2 NS, Potassium Chloride, D5 + 20meq K@75, TF@10\n Consults: General surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:45 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 07:25 AM\n 20 Gauge - 11:30 AM\n Multi Lumen - 11:43 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2187-07-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685882, "text": "Demographics\n No longer intubated\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Some accessoru muscle use, long\n exp time\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Plan\n Next 24-48 hours:\n Monitor and support as needed\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685773, "text": "53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with midline abdominal incision from tumor resection. Dressing\n intact as incision putting out only small amounts of serous drainage\n HCT remains stable at 27.4 this AM\n Pt extubated yesterday. ABG at baseline. LS rhonchourous and pt having\n difficult time raising up sputum with cough\n Pt afebrile\n Action:\n Albuterol/atrovent nebulizers given. CPT done to help pt clear\n secretions\n Response:\n Pt able to raise more secretions with pulmonary toiler\n Plan:\n Continue CPT as needed, nebulizers as needed. Abdominal assessments\n every 4 hours and PRN\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt\ns fentanyl drip weaned to off. BP elevated into 180s and pt\n transiently tachycardic with elevated pain\n Action:\n Pt getting intermittent bolus dosing of fentanyl\n Response:\n Pt reports adequate pain relief\n Plan:\n Monitor pain level, medicate PRN\n" }, { "category": "Nursing", "chartdate": "2187-07-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684731, "text": "53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt to ED today for 3 days of weakness/fatigue, N/V. Upon arrival\n to , pt hypotensive with HCT 23, found to have GIB. In , pt given\n 4L IVF, IV erythromycin, IV protonix, 1 unit PRBCs, seen by GI and NG\n lavaged for 300cc old red blood, and sent to unit.\n Action:\n Upon arrival to unit, EGD performed by GI team showing large amts old\n blood but no s/s active bleeding. GI unable to see source of bleed \n large amts clot/blood. Pt transfused 2 more units PRBCs and 1L IVF for\n hypotension into 70s. Repeat HCT down to 22.9 but in the setting of\n large amts IVF. Given 80mg IV protonix bolus, then started on protonix\n gtt @ 8mg/hr.\n Response:\n BPs stabilizing in 90s. Pt cont with dark, guiac positive stools but no\n further emesis.\n Plan:\n Pt to cont on protonix gtt @ 8mg/hr. Monitor HCTs Q6. Monitor for s/s\n bleeding. Treat hypotension with IVF and PRBCs. Cont NPO for now with\n plan for possible re-scope tomorrow or Thursday.\n" }, { "category": "Nursing", "chartdate": "2187-07-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684783, "text": "TITLE:\n 53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient had 1 melnotic stool in pm. Completed 3^rd unit of PrBC\n Action:\n Hct checked at hrs- hct 25.8( Goal -25 ). Repeat Hct at midnight\n 25.9\n Response:\n Plan:\n Will continue monitoring.\n" }, { "category": "Physician ", "chartdate": "2187-07-24 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 684722, "text": "Chief Complaint: GI bleed, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 53 yr old gentleman with HTN COPD DM type 2 developed abd pain nausea\n and vomiting 3 days PTA- dark black emesis and melena. he did not seek\n care until this AM, dizzy, called 911. En route ? elevations On\n arrival to ED STEMI actiavetd but repeat 12 lead without acute ECG\n changes.\n No cardiac hx. Initial trop 0.05 CK 28\n Vitals afebrile HR 99 BP 90/29 18 95% RA - pale. HCT 23.7 (no baseline)\n lactate 2.7 - wbc 20K normal plts and coags. NG lavage dark red, not\n clear with 300 CC saline\n Given 4L saline, started on 2 units PRBC, and GI called for urgent EGD\n then sent to MICU\n On arrival to MICU EGD w clot in fundus, no source identified - decent\n but incomplete visual so may need rescope\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n COPD/asthma\n PTX with bleb rupture\n DM2\n chronic knee pain obn oxycontin\n Home Meds: Metformin, Lisinopril, cholesterol med\n no CAD no GI bleed\n Occupation: owns a pizza shop in \n Drugs: neg\n Tobacco: active 2PPD\n Alcohol: denies but ? by PCP\n : married with 2 children\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, Tachycardia\n Gastrointestinal: Emesis, Diarrhea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Flowsheet Data as of 05:21 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 89 (85 - 97) bpm\n BP: 92/73(77) {58/30(38) - 109/73(77)} mmHg\n RR: 26 (21 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,801 mL\n PO:\n TF:\n IVF:\n 1,020 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 1,325 mL\n Urine:\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,476 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: no edema\n Skin: Warm\n Neurologic: Attentive,\n Labs / Radiology\n 437\n 23.7\n 209\n 1.6\n 73\n 24\n 98\n 4.3\n 134\n 20.1\n [image002.jpg]\n Other labs: PT / PTT / INR://13/22/1.1, ALT / AST:/,\n Differential-Neuts:81, Band:0, Lymph:14, Ca++:8, Mg++:2, PO4:4.4\n ECG: sinus rhythm with normal axis j point in II,III, F no reciprocal\n changes\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n 1. GI bleed: etiology unclear- upper source but could not localize\n ulceration - but could be hidden by clot etc. we will transfuse cycle\n HCT q4-6, give another unit blood. PPI drip. repeat EGD in 24-48 hours\n or sooner. He has 2 lareg bore , move to cordis if\n hemodynamically unstable.\n 2. ? ECG changes in field, cycle cks, repeat ECG in AM, hold ASA,\n cannot get bblockers\n 3. DM: SSRI\n 4. Remaining issues as per Housestaff\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 16 Gauge - 03:59 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: with patient, wife is out of town\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2187-07-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684723, "text": "53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684860, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 88 (79 - 98) bpm\n BP: 111/68(79) {58/30(38) - 123/73(79)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 65 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 65 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,030 mL\n Urine:\n 1,480 mL\n 2,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -1,965 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 25.4 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2187-07-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684871, "text": "TITLE:\n 53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Patient alert, Oriented x 3.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient had 1 melnotic stool in pm. Completed 3^rd unit of PrBC. Has\n PIV x 2\n Action:\n Hct checked at hrs- hct 25.8( Goal is 25 ). Repeat Hct at midnight\n 25.9\n Response:\n Hct at 4am 25.4\n Plan:\n Will continue monitoring. Hct q 6 hrs.\n Mag & Phos will need repletion, awaiting orders.\n" }, { "category": "Nursing", "chartdate": "2187-07-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684874, "text": "TITLE:\n 53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Patient alert, Oriented x 3.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient had 1 melnotic stool in pm. Completed 3^rd unit of PrBC. Has\n PIV x 2\n Action:\n Hct checked at hrs- hct 25.8( Goal is 25 ). Repeat Hct at midnight\n 25.9\n Response:\n Hct at 4am 25.4\n Plan:\n Will continue monitoring. Hct q 6 hrs.\n Mag & Phos will need repletion, awaiting orders.\n ------ Protected Section ------\n Continued on PAntoprazole drip at 8 mgs/hour.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:37 ------\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684877, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n EGD with visualization of clot in stomach but with no sign of ongoing\n bleed. Hct stable at 25-26 s/p third unit of pRBC given at 5pm\n yesterday.\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 88 (79 - 98) bpm\n BP: 111/68(79) {58/30(38) - 123/73(79)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 64 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 64 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,030 mL\n Urine:\n 1,480 mL\n 2,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -1,966 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), DISTANT BREATH SOUNDS\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 25.4 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Imaging: egd: Normal mucosa in the esophagus\n Blood in the stomach body and fundus\n Normal mucosa in the duodenum\n Otherwise normal EGD to second part of the duodenum\n Microbiology: none\n ECG: repeat am ekg:\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: This is a 53yo M with HTN, DMII, COPD who presents\n with sub-acute upper GIB for four days with no visualization of active\n bleed on EGD. Hemodynamically stable and with stable Hct x 12 hours s/p\n transfusion of 3 units of pRBC.\n .\n # UGIB: 6L of fluid given between 5 L NS and Prbc x3. Hct stable since\n last unit. Hemodynamically stable. BP normal off home anti-, may\n still be low for him. No additional melena or emesis. Overall, no\n indication of continued bleeding overnight.\n - Q6H Hct today, TRANSFUSION GOAL 25, IVF bolus PRN for hypotension\n - IV PPI drip, will transition to IV PPI \n - D/W GI re: timing of repeat EGD and dispo\n - If decompesates, would consider tagged red cell scan\n - maintain two peripheral IVs, would prefer to get another 16 given\n magnitude of initial bleed\n .\n # HTN: Holding all outpt antiHTN given low-normal BP currently\n .\n # DMII: holding metformin. SSI while inpt.\n # EKG abnl: As above, likely spurious tracing by EMS 12-lead, but also\n possibly rate related HR=127 in ambulance. Low suspicion for ACS. Ruled\n out with trop 0.05\n0.03 and flat CK\n .\n # HLD: will try to determine outpt regimen\n .\n # Chronic pain: states currently dose not need home oxycontin. Could\n start prn\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: HOLD Subcutaneous heparin\n # Access: peripherals 16 AND 20 (other 16 lost)\n # Code: CONFIRMED full\n # Communication: Patient\n # Disposition: pending above , d/w GI re: rpt scope\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-07-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 684776, "text": "Chief Complaint: UGIB\n HPI:\n 53M with a PMHx of HTN, DMII, COPD, developed dizzyness with nausea,\n stomach pain, and vomitting 3-4 days prior to admission. Emesis was\n dark black. Melanotic stools began on saturday and continued for three\n days until admission. This morning dizzyness and weakness progressed,\n he called 911 and was brought to ED by EMS. In the ambulance, was noted\n to have inferior ST elevations (got ASA 325 by EMS). These resolved on\n the ED 12-lead and were attributed to machine calibration; he does not\n have a cardiac hx and had no chest pain. Trop on arrival 0.05, CK=28\n (Cr at 1.6, baseline unknown).\n .\n In the ED, initial vs were: T=96.8 P=99 BP=90/29 R=20 O2 sat 95%.\n Patient was pale and diaphoretic at presentation c/o weakness. His\n initial Hct was 23.7 (unknown baseline) with WBC of 20, normal plts,\n normal coags. His pants were stained with melanotic stool. NG drainage\n was drak red and did not clear with lavage. He was given 4L NS (1 prior\n to Hct, 3 post) and erythromycin for motility prior to EGD. Pressure\n transiently as low as 81/28 in the ED, at time of transfer (POST 4L),\n HR=86, BP=105/60, R=20, 96%ra. One unit of blood given in transit and\n second unit given over one hour in MICU.\n .\n EGD in MICU showed clot in fundus with no active bleeding. Currently\n feels weak but significatly better than earlier today. Denies ever\n having had chest pain. Denies GIB hx, ulcer hx, etoh abuse, denies\n excess NSAID use. Never had stomach pain before 4 days PTA.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. No dysuria. Denied arthralgias or myalgias. PCP informed\n of admission; has not seen him in one year.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n home meds\n metformin dose unknown\n oxycontin 20mg prn for knee pain on ambulation\n lisinopril dose unknown\n cholesterol med--unknown\n Past medical history:\n Family history:\n Social History:\n Chronic pain on home opiates\n s/p MVA with femur fx 20+ years ago\n R knee OA\n HTN\n COPD/asthma\n Hypercholesterolemia\n Hospitalization for PTX s/p bleb rupture several years ago.\n no hx CAD, malignancy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is married, has two children. Denies alcohol or drug\n use. He currently smokes 2 packs of cigarettes per day. He works and\n owns a pizza shop in . Wife is travelling in and has been\n updated.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Signs or concerns for abuse : No\n Flowsheet Data as of 07:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 87 (85 - 98) bpm\n BP: 91/32(46) {58/30(38) - 109/73(77)} mmHg\n RR: 19 (19 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,100 mL\n PO:\n TF:\n IVF:\n 1,038 mL\n Blood products:\n 562 mL\n Total out:\n 0 mL\n 1,325 mL\n Urine:\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,775 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 291 K/uL\n 7.9 g/dL\n 22.9 %\n 11.5 K/uL\n [image002.jpg]\n \n 2:33 A6/30/ 05:01 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.5\n Hct\n 22.9\n Plt\n 291\n Imaging: cxr; hyperinfalted lung filds, no consolidation\n Microbiology: none\n ECG: NSR, rightward axis, j-point elevations inferiorly (<1mm)\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: This is a 53yo M with HTN, DMII, COPD who presents\n with sub-acute upper GIB for four days with no visualization of active\n bleed on EGD. Hemodynamically stable.\n .\n # UGIB: No history of PUD, NSAID overuse, liver dz, or ETOH abuse. EGD\n showing significant clot in stomach with no active bleeding. S/p 4LNS\n in ED and s/p 2 units of blood with resolution of tachycardia and\n low-normal blood pressure.\n - continuous vital monitoring, no indication for a-line currently\n - Q6H HCT overnight, TRANSFUSION GOAL 25 (given possibility of active\n bleeding), IVF bolus PRN for hypotension\n - IV PPI drip\n - repeat EGD in 24-48 hrs\n - If decompesates, would consider tagged red cell scan\n - maintain two peripheral 16 gauge IVs\n .\n # HTN: Holding all outpt antiHTN given low-normal BP currently\n .\n # DMII: holding metformin given hypovolemia and elevated lactate at\n presentaion. SSI while inpt.\n # EKG abnl: As above, likely spurious tracing by EMS 12-lead, but also\n possibly rate related HR=127 in ambulance. Low suspicion for ACS.\n - 3 sets CE\n .\n # HLD: will try to determine outpt regimen\n .\n # Chronic pain: states currently dose not need home oxycontin. would be\n reluctant given hypotension\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: HOLD Subcutaneous heparin\n # Access: peripherals 16 AND 16\n # Code: CONFIRMED full\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 03:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684868, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n EGD with visualization of clot in stomach but with no sign of ongoing\n bleed. Hct stable at 25-26 s/p third unit of pRBC given at 5pm\n yesterday.\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 88 (79 - 98) bpm\n BP: 111/68(79) {58/30(38) - 123/73(79)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 64 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 64 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,030 mL\n Urine:\n 1,480 mL\n 2,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -1,966 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), DISTANT BREATH SOUNDS\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 25.4 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Imaging: egd: Normal mucosa in the esophagus\n Blood in the stomach body and fundus\n Normal mucosa in the duodenum\n Otherwise normal EGD to second part of the duodenum\n Microbiology: none\n ECG: repeat am ekg:\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684870, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n - EGD no obvious source of bleeding. Clot in stomach easily moved and\n now source seen below. Plan to re-scope in 24-48hrs. IV PPI,\n transfuse to maintain crit.\n -2130: s/p 3units pRBC. Next Hct at 0000hrs.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Insulin\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 88 (79 - 98) bpm\n BP: 111/68(79) {58/30(38) - 123/73(79)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 65 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 65 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,030 mL\n Urine:\n 1,480 mL\n 2,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -1,965 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, distant BS, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, DISTANT S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 25.4 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 53yo M with HTN, DMII, COPD who presents\n with sub-acute upper GIB for four days with no visualization of active\n bleed on EGD. Hemodynamically stable.\n .\n # UGIB: No history of PUD, NSAID overuse, liver dz, or ETOH abuse. EGD\n showing significant clot in stomach with no active bleeding. S/p 4LNS\n in ED and s/p 2 units of blood with resolution of tachycardia and\n low-normal blood pressure (given Pts h/o HTN and having not taken Rx in\n 24hrs.).\n - Hemodynamically stable at present.\n - HCT stable throughout the night. TRANSFUSION GOAL 25 (given\n possibility of active bleeding),\n - IVF bolus PRN for hypotension and transfusion PRN\n - IV PPI drip\n - repeat EGD in 24-48 hrs\n - If decompensate, would consider tagged red cell scan\n - maintain two peripheral 16 gauge IVs\n .\n # HTN: Holding all outpt antiHTN given low-normal BP currently\n .\n # DMII: holding metformin given hypovolemia and elevated lactate at\n presentaion. SSI while inpt.\n # EKG abnl: As above, likely spurious tracing by EMS 12-lead, but also\n possibly rate related HR=127 in ambulance. Low suspicion for ACS.\n - 3 sets CE\n .\n # HLD: will try to determine outpt regimen\n .\n # Chronic pain: states currently does not need home oxycontin. would be\n reluctant given hypotension\n .\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: SCD\n Stress ulcer: IV PPI gtt\n VAP: n/a\n Comments:\n Communication: With Patient Comments:\n Code status: Full code\n Disposition: To floor if remains stable pending discussion with GI re :\n EGD today.\n" }, { "category": "Nursing", "chartdate": "2187-07-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 686031, "text": "53M developed dizziness with nausea, stomach pain, and vomiting 3-4 days prior\nto admission. Emesis was dark black. Melanotic stools began on and continue\nd for three days until admission. AM , dizziness and weakness progressed; he\n called 911 and was brought to ED by EMS.\n In the ED, patient was pale and diaphoretic & c/o weakness. His initial\n Hct was 23.7 (unknown baseline) with WBC of 20, normal plts, normal\n coags. His pants were stained with melanotic stool. NG drainage was\n dark red and did not clear with lavage. He was given 4L NS (1 prior to\n Hct, 3 post) and erythromycin for motility prior to EGD. Pressure\n transiently as low as 81/28 in the ED.\n EGD in MICU showed clot in fundus with no active bleeding. Denies\n GIB hx, ulcer hx, etoh abuse, denies excess NSAID use. Never had\n stomach pain before 4 days PTA. Transferred out to 2 on then\n vomitted a large amt of BRB. NGT placed w/ and additional 1 L BRB out.\n Transferred to SICU w/ EGD on arrival; taken emergently to OR for\n subtotal gastrectomy of tumor. Intra-op found to have adenocarcinoma.\n Dr. spoke w/ pt\ns wife post-op and given poor prognosis of less\n than 3-6 months.\nPMH: HTN, Hyperlipidemia, DMII, hypercholesterolemia, COPD on 2L home O2 (quest\nionable compliance)\n Asthma, MVA with right femur fracture in , right knee\n osteoarthritis on home opiates, hospitalization for pneumothorax\n s/p bleb rupture several years ago\n Pneumonia, other\n Assessment:\n Received on 50% face tent. Sats 93-95%. Cough weak w/ scant pale yellow\n secretions.\n Action:\n OOB to chair.\n Instructed to CDB.\n Nebs given as ordered.\n Bilat CPT.\n Response:\n Weaned down to 3L NC Sats 96-98%.\n LS occ scattered rhonci that clears w/ cough. Exp wheeze clears with\n nebs. Dim bases.\n Cough congested/productive and stronger while in chair.\n Plan:\n Cont. Aggressive pulm toilet.\n OOB as much as tolerated.\n Nebs as ordered.\n TX to floor on when bed avail.\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 85 kg\n Daily weight:\n 94 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, COPD, Diabetes - Oral , Smoker\n CV-PMH: Hypertension\n Additional history: hyperlipidemia\n spontaneous PNX from Blebs\n Surgery / Procedure and date: Ex lap s/p subtotal gastrectomy.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:137\n D:62\n Temperature:\n 97.9\n Arterial BP:\n S:127\n D:73\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 3% %\n 24h total in:\n 1,253 mL\n 24h total out:\n 2,390 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:00 AM\n Potassium:\n 3.9 mEq/L\n 03:00 AM\n Chloride:\n 103 mEq/L\n 03:00 AM\n CO2:\n 34 mEq/L\n 03:00 AM\n BUN:\n 10 mg/dL\n 03:00 AM\n Creatinine:\n 0.4 mg/dL\n 03:00 AM\n Glucose:\n 105 mg/dL\n 03:29 AM\n Hematocrit:\n 25.5 %\n 03:00 AM\n Finger Stick Glucose:\n 179\n 04:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicua 693\n Transferred to: 540\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685840, "text": "Pneumonia, other\n Assessment:\n RR 30-40\ns labored. Sats 85 on 70% face tent. Diaphoretic. Ls dim.\n Bilat.\n Action:\n Neb TX given\n Placed on 100% NRB.\n Sicu resident , MD notified.\n Enc to CDB/ Bilat CPT\n CTA ordered and completed.\n Response:\n Sats slowly recovered to 100%. RR down 18-24. LS clear with dim bases.\n Switched back to Face tent 70%. Sats slowly started to drop down again\n to 87-88%.\n 4L NC placed in addition to 70% face tent\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685934, "text": "Pneumonia, other\n Assessment:\n Breath sounds wheezy in upper lobes at times.\n Transient episode of desaturation to 89%.\n CT scan negative for pulmonary embolism, positive for pneumonia.\n Action:\n Deep breath and coughing exercises encouraged.\n O2 50% via face tent.\n Nebs q4 as ordered.\n Dr discussed result of CT scan with pts brother.\n Antibiotics, zosyn and vanco dosed.\n Response:\n Responded well to breathing exercises and nebs.\n Coughing and raising small but frequent amounts of pale yellow\n secretions.\n O2 sats generally maintained >95%.\n Patient had a well rested night overall.\n WBC down this am.\n Pt afebrile.\n Plan:\n Continue to encourage breath/coughing exercises, clearance of\n secretions.\n Abx as ordered.\n Incentive spirometry.\n" }, { "category": "Physician ", "chartdate": "2187-07-31 00:00:00.000", "description": "Intensivist Note", "row_id": 685936, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p subtotal\n gastrectomy, Billroth 2.\n Chief complaint:\n gastric CA\n PMHx:\n HTN, DMII, COPD with home O2, smoker\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 0650\n 14. Lisinopril 20 mg PO DAILY\n MAP > 60 Order date: @ \n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 2111 15. Magnesium\n Sulfate IV Sliding Scale Order date: @ 0727\n 3. Acetylcysteine 20% 3-5 mL NEB Q6H:PRN thick secretions Order date:\n @ 0350 16. Phenylephrine 0.5-3 mcg/kg/min IV DRIP TITRATE TO MAPS\n >60 Order date: @ 0329\n 4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H sob Order date: @ 1842\n 17. Piperacillin-Tazobactam 4.5 gm IV ONCE Duration: 1 Doses Order\n date: @ 0811\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 0829 18.\n Piperacillin-Tazobactam 4.5 g IV ONCE Duration: 1 Doses Start: \n Order date: @ 2205\n 6. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1427 19.\n Piperacillin-Tazobactam 4.5 g IV Q8H *Awaiting ID Approval* Order date:\n @ 0401\n 7. Famotidine 20 mg IV Q12H Order date: @ 0818 20. Potassium\n Chloride IV Sliding Scale Order date: @ 0727\n 8. Furosemide 5 mg IV ONCE Duration: 1 Doses Order date: @ 1059\n 21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0650\n 9. HYDROmorphone (Dilaudid) 1 mg IV ONCE Duration: 1 Doses Order date:\n @ 0942 22. Sodium Phosphate IV Sliding Scale Order date: @\n 0727\n 10. HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes\n Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s) Order date: @\n 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 2111\n 11. Heparin 5000 UNIT SC TID Order date: @ 1055 24. Vancomycin\n 1000 mg IV ONCE ?HAP Duration: 1 Doses Order date: @ 0811\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0711 25. Vancomycin 1000 mg IV\n Q 12H ?HAP\n ID Approval will be required for this order in 51 hours. Order date:\n @ 0811\n 13. Ipratropium Bromide Neb 1 NEB IH Q4H sob Order date: @\n 1842\n 24 Hour Events:\n ULTRASOUND - At 10:33 AM\n Post operative day:\n POD#4 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:05 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:45 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:19 AM\n Hydromorphone (Dilaudid) - 08:30 AM\n Furosemide (Lasix) - 12:09 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:12 AM\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.6\nC (97.8\n HR: 104 (94 - 106) bpm\n BP: 138/66(88) {119/56(75) - 175/88(112)} mmHg\n RR: 18 (14 - 27) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94 kg (admission): 85 kg\n Height: 68 Inch\n CVP: 7 (4 - 15) mmHg\n Total In:\n 1,456 mL\n 156 mL\n PO:\n Tube feeding:\n 240 mL\n 52 mL\n IV Fluid:\n 1,126 mL\n 104 mL\n Blood products:\n Total out:\n 1,810 mL\n 290 mL\n Urine:\n 1,810 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -354 mL\n -135 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 97%\n ABG: 7.35/71/122/34/10\n PaO2 / FiO2: 244\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffuse, Diminished: LLL)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 336 K/uL\n 8.7 g/dL\n 105 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 10 mg/dL\n 103 mEq/L\n 142 mEq/L\n 25.5 %\n 10.8 K/uL\n [image002.jpg]\n 02:03 AM\n 04:41 AM\n 10:27 AM\n 12:54 PM\n 02:09 PM\n 02:16 AM\n 02:39 AM\n 12:29 PM\n 03:00 AM\n 03:29 AM\n WBC\n 12.3\n 10.8\n Hct\n 25.6\n 27.4\n 25.5\n Plt\n 268\n 336\n Creatinine\n 0.5\n 0.4\n TCO2\n 35\n 35\n 36\n 37\n 37\n 36\n 41\n Glucose\n 107\n 111\n 105\n Other labs: PT / PTT / INR:11.9/23.3/1.0, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:104/53, Alk-Phos / T bili:54/0.4, Amylase /\n Lipase:48/, Fibrinogen:591 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.3\n g/dL, LDH:132 IU/L, Ca:7.9 mg/dL, Mg:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER, ACIDOSIS, RESPIRATORY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 53M with gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II\n Neuro: On Dilaudid PCA. Pain well controlled.\n CVS: Not on pressors. Became transiently hypotensive with turns +\n suction. MAP>60, phenylephrine drip ordered if needed. cont. lisinopril\n 20\n Pulm: Extubated POD2. Developing RLL PNA. Will start Vanc/Zosyn.\n CTAngio neg PE awaiting final read, Pulm toilet. Nebs. Will need OOB.\n wean to NC\n GI: NPO w/ trophic TF, advance TF, sips\n FEN: KVO, TF@10 13L positive\n Renal: pt w/ good U/O. Diamox 250 mg for diuresis\n Heme: Hct Stable 25.5. HSQ\n Endo: RISS\n ID: vanc/zosyn for HAP\n TLD: JT, RIJ, Aline, PIV, foley\n Wounds: Abd\n Imaging: CTA neg PE awaiting final read, CXR am\n Prophylaxis: H2B, HSQ\n Consults: GI, East\n Code: Full\n Disposition: SICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 07:25 AM\n Multi Lumen - 11:43 AM\n 20 Gauge - 02:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2187-07-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 686005, "text": "53M developed dizziness with nausea, stomach pain, and vomiting 3-4 days prior\nto admission. Emesis was dark black. Melanotic stools began on and continue\nd for three days until admission. AM , dizziness and weakness progressed; he\n called 911 and was brought to ED by EMS.\n In the ED, patient was pale and diaphoretic & c/o weakness. His initial\n Hct was 23.7 (unknown baseline) with WBC of 20, normal plts, normal\n coags. His pants were stained with melanotic stool. NG drainage was\n dark red and did not clear with lavage. He was given 4L NS (1 prior to\n Hct, 3 post) and erythromycin for motility prior to EGD. Pressure\n transiently as low as 81/28 in the ED.\n EGD in MICU showed clot in fundus with no active bleeding. Denies\n GIB hx, ulcer hx, etoh abuse, denies excess NSAID use. Never had\n stomach pain before 4 days PTA. Transferred out to 2 on then\n vomitted a large amt of BRB. NGT placed w/ and additional 1 L BRB out.\n Transferred to SICU w/ EGD on arrival; taken emergently to OR for\n subtotal gastrectomy of tumor. Intra-op found to have adenocarcinoma.\n Dr. spoke w/ pt\ns wife post-op and given poor prognosis of less\n than 3-6 months.\nPMH: HTN, Hyperlipidemia, DMII, hypercholesterolemia, COPD on 2L home O2 (quest\nionable compliance)\n Asthma, MVA with right femur fracture in , right knee\n osteoarthritis on home opiates, hospitalization for pneumothorax\n s/p bleb rupture several years ago\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2187-07-31 00:00:00.000", "description": "Intensivist Note", "row_id": 685901, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p subtotal\n gastrectomy, Billroth 2.\n Chief complaint:\n gastric CA\n PMHx:\n HTN, DMII, COPD with home O2, smoker\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 0650\n 14. Lisinopril 20 mg PO DAILY\n MAP > 60 Order date: @ \n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 2111 15. Magnesium\n Sulfate IV Sliding Scale Order date: @ 0727\n 3. Acetylcysteine 20% 3-5 mL NEB Q6H:PRN thick secretions Order date:\n @ 0350 16. Phenylephrine 0.5-3 mcg/kg/min IV DRIP TITRATE TO MAPS\n >60 Order date: @ 0329\n 4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H sob Order date: @ 1842\n 17. Piperacillin-Tazobactam 4.5 gm IV ONCE Duration: 1 Doses Order\n date: @ 0811\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 0829 18.\n Piperacillin-Tazobactam 4.5 g IV ONCE Duration: 1 Doses Start: \n Order date: @ 2205\n 6. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1427 19.\n Piperacillin-Tazobactam 4.5 g IV Q8H *Awaiting ID Approval* Order date:\n @ 0401\n 7. Famotidine 20 mg IV Q12H Order date: @ 0818 20. Potassium\n Chloride IV Sliding Scale Order date: @ 0727\n 8. Furosemide 5 mg IV ONCE Duration: 1 Doses Order date: @ 1059\n 21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0650\n 9. HYDROmorphone (Dilaudid) 1 mg IV ONCE Duration: 1 Doses Order date:\n @ 0942 22. Sodium Phosphate IV Sliding Scale Order date: @\n 0727\n 10. HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes\n Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s) Order date: @\n 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 2111\n 11. Heparin 5000 UNIT SC TID Order date: @ 1055 24. Vancomycin\n 1000 mg IV ONCE ?HAP Duration: 1 Doses Order date: @ 0811\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0711 25. Vancomycin 1000 mg IV\n Q 12H ?HAP\n ID Approval will be required for this order in 51 hours. Order date:\n @ 0811\n 13. Ipratropium Bromide Neb 1 NEB IH Q4H sob Order date: @\n 1842\n 24 Hour Events:\n ULTRASOUND - At 10:33 AM\n Post operative day:\n POD#4 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:05 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:45 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:19 AM\n Hydromorphone (Dilaudid) - 08:30 AM\n Furosemide (Lasix) - 12:09 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:12 AM\n Other medications:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.6\nC (97.8\n HR: 104 (94 - 106) bpm\n BP: 138/66(88) {119/56(75) - 175/88(112)} mmHg\n RR: 18 (14 - 27) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94 kg (admission): 85 kg\n Height: 68 Inch\n CVP: 7 (4 - 15) mmHg\n Total In:\n 1,456 mL\n 156 mL\n PO:\n Tube feeding:\n 240 mL\n 52 mL\n IV Fluid:\n 1,126 mL\n 104 mL\n Blood products:\n Total out:\n 1,810 mL\n 290 mL\n Urine:\n 1,810 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -354 mL\n -135 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 97%\n ABG: 7.35/71/122/34/10\n PaO2 / FiO2: 244\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffuse, Diminished: LLL)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 336 K/uL\n 8.7 g/dL\n 105 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 10 mg/dL\n 103 mEq/L\n 142 mEq/L\n 25.5 %\n 10.8 K/uL\n [image002.jpg]\n 02:03 AM\n 04:41 AM\n 10:27 AM\n 12:54 PM\n 02:09 PM\n 02:16 AM\n 02:39 AM\n 12:29 PM\n 03:00 AM\n 03:29 AM\n WBC\n 12.3\n 10.8\n Hct\n 25.6\n 27.4\n 25.5\n Plt\n 268\n 336\n Creatinine\n 0.5\n 0.4\n TCO2\n 35\n 35\n 36\n 37\n 37\n 36\n 41\n Glucose\n 107\n 111\n 105\n Other labs: PT / PTT / INR:11.9/23.3/1.0, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:104/53, Alk-Phos / T bili:54/0.4, Amylase /\n Lipase:48/, Fibrinogen:591 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.3\n g/dL, LDH:132 IU/L, Ca:7.9 mg/dL, Mg:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER, ACIDOSIS, RESPIRATORY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 53M with gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II\n Neuro: Fent for pain control. Need PO.\n CVS: Not on pressors. Became transiently hypotensive with turns +\n suction. MAP>60, phenylephrine drip ordered if needed. cont. lisinopril\n 20\n Pulm: Extubated POD2. Developing RLL PNA. Will start Vanc/Zosyn.\n CTAngio neg PE, Pulm toilet. Nebs. Will need OOB\n GI: NPO w/ trophic TF, ? sips\n FEN: D5 + 20meq K@75, TF@10 13L positive\n Renal: pt w/ good U/O. cont. Lasix 5mg\n Heme: Hct Stable 25.5.\n Endo: RISS\n ID: vanc/zosyn for HAP\n TLD: JT, RIJ, Aline, PIV, foley (? DC)\n Wounds: Abd\n Imaging: CTA neg PE, CXR am\n Prophylaxis: H2B, HSQ\n Consults: GI, East\n Code: Full\n Disposition: SICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 07:25 AM\n Multi Lumen - 11:43 AM\n 20 Gauge - 02:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2187-07-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684756, "text": "53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt to ED today for 3 days of weakness/fatigue, N/V. Upon arrival\n to , pt hypotensive with HCT 23, found to have GIB. In , pt given\n 4L IVF, IV erythromycin, IV protonix, 1 unit PRBCs, seen by GI and NG\n lavaged for 300cc old red blood, and sent to unit.\n Action:\n Upon arrival to unit, EGD performed by GI team showing large amts old\n blood but no s/s active bleeding. GI unable to see source of bleed \n large amts clot/blood. Pt transfused 2 more units PRBCs and 1L IVF for\n hypotension into 70s. Repeat HCT down to 22.9 but in the setting of\n large amts IVF. Given 80mg IV protonix bolus, then started on protonix\n gtt @ 8mg/hr.\n Response:\n BPs stabilizing in 90s. Pt cont with dark, guiac positive stools but no\n further emesis.\n Plan:\n Pt to cont on protonix gtt @ 8mg/hr. Monitor HCTs Q6. Monitor for s/s\n bleeding. Treat hypotension with IVF and PRBCs. Cont NPO for now with\n plan for possible re-scope tomorrow or Thursday.\n" }, { "category": "Nursing", "chartdate": "2187-07-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 685996, "text": "PMhx: HTN, Hyperlipidemia, DMII, hypercholesterolemia, COPD on 2L home O2 (ques\ntionable compliance)\n Asthma, MVA with right femur fracture in , right knee osteoarthritis on \ne opiates, hospitalization for pneumothorax s/p bleb rupture several years ago.\nMedications prior to hospital admission:\n- HCTZ 25mg PO daily\n- lisinopril 20mg PO daily\n- atenolol 50mg PO daily\n- simvastatin 10mg qhs\n- oxycontin 20 PO BID\n- advair diskus 250/50\n- spiriva\n- fenofibrate cap 200mg (1 cap PO daily with meals)\n- metformin 500mg tab \n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 686013, "text": "53M developed dizziness with nausea, stomach pain, and vomiting 3-4 days prior\nto admission. Emesis was dark black. Melanotic stools began on and continue\nd for three days until admission. AM , dizziness and weakness progressed; he\n called 911 and was brought to ED by EMS.\n In the ED, patient was pale and diaphoretic & c/o weakness. His initial\n Hct was 23.7 (unknown baseline) with WBC of 20, normal plts, normal\n coags. His pants were stained with melanotic stool. NG drainage was\n dark red and did not clear with lavage. He was given 4L NS (1 prior to\n Hct, 3 post) and erythromycin for motility prior to EGD. Pressure\n transiently as low as 81/28 in the ED.\n EGD in MICU showed clot in fundus with no active bleeding. Denies\n GIB hx, ulcer hx, etoh abuse, denies excess NSAID use. Never had\n stomach pain before 4 days PTA. Transferred out to 2 on then\n vomitted a large amt of BRB. NGT placed w/ and additional 1 L BRB out.\n Transferred to SICU w/ EGD on arrival; taken emergently to OR for\n subtotal gastrectomy of tumor. Intra-op found to have adenocarcinoma.\n Dr. spoke w/ pt\ns wife post-op and given poor prognosis of less\n than 3-6 months.\nPMH: HTN, Hyperlipidemia, DMII, hypercholesterolemia, COPD on 2L home O2 (quest\nionable compliance)\n Asthma, MVA with right femur fracture in , right knee\n osteoarthritis on home opiates, hospitalization for pneumothorax\n s/p bleb rupture several years ago\n Pneumonia, other\n Assessment:\n Received on 50% face tent. Sats 93-95%. Cough weak w/ scant pale yellow\n secretions.\n Action:\n OOB to chair.\n Instructed to CDB.\n Nebs given as ordered.\n Bilat CPT.\n Response:\n Weaned down to 3L NC Sats 96-98%.\n LS occ scattered rhonci that clears w/ cough. Exp wheeze clears with\n nebs. Dim bases.\n Cough congested/productive and stronger while in chair.\n Plan:\n Cont. Aggressive pulm toilet.\n OOB as much as tolerated.\n Nebs as ordered.\n TX to floor on when bed avail.\n" }, { "category": "Nursing", "chartdate": "2187-07-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 684972, "text": "53M with a PMHx of HTN, DMII, COPD, developed dizziness with nausea,\n stomach pain, and vomiting 3-4 days prior to admission. Emesis was dark\n black. Melanotic stools began on and continued for three days\n until admission. AM , dizzyness and weakness progressed, he called\n 911 and was brought to ED by EMS. In the ambulance, was noted to have\n inferior ST elevations (got ASA 325 by EMS). These resolved on the ED\n 12-lead and were attributed to machine calibration; he does not have a\n cardiac hx and had no chest pain. Trop on arrival 0.05, CK=28 (Cr at\n 1.6, baseline unknown).\n .\n In the ED, patient was pale and diaphoretic & c/o weakness. His initial\n Hct was 23.7 (unknown baseline) with WBC of 20, normal plts, normal\n coags. His pants were stained with melanotic stool. NG drainage was\n dark red and did not clear with lavage. He was given 4L NS (1 prior to\n Hct, 3 post) and erythromycin for motility prior to EGD. Pressure\n transiently as low as 81/28 in the ED.\n EGD in MICU showed clot in fundus with no active bleeding. Denies\n ever having had chest pain. Denies GIB hx, ulcer hx, etoh abuse, denies\n excess NSAID use. Never had stomach pain before 4 days PTA.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt X 3, OOB to commode with minimal assist. Denies pain. Occas\n taking off sat prob and threatening to take out IV. VSS with HR 85-98SR\n without VEA. BP 117/76-147/71. Lungs clear, RR 19-25 and regular, O2\n sat 95-97% on RA. Tmax 99.2po. Abd soft with +BS and flatus, but no BM\n since yesterday when he had 2 large, black , guaiac pos movements. Pt\n NPO except for ice chips. Voiding clear yellow urine in lg amts, with\n fluid balance since MN -2.6liters, LOS balance +1.2liters. AM Hct 25.4,\n Mg 1.9. Rec\nd on Pantoprazole qtt @ 8mg/hr.\n Action:\n Repeat Hct @ 1030 was 26.3. KVO NS infusing via #16 periph IV. Pt also\n has a #20. Mg repleted. Pantoprozole qtt D/C\nd @ 1030, and pt started\n on doses.\n Response:\n Hct remains stable. Pt remains pale and feels weak but no other\n complaints.\n Plan:\n Pt has remained NPO for possible repeat EGD. Next Hct due @ 1500.\n Transfer to floor.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 89.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD, Diabetes - Oral , Smoker\n CV-PMH: Hypertension\n Additional history: hyperlipidemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:71\n Temperature:\n 99\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 190 mL\n 24h total out:\n 2,830 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:42 AM\n Potassium:\n 4.3 mEq/L\n 04:42 AM\n Chloride:\n 105 mEq/L\n 04:42 AM\n CO2:\n 31 mEq/L\n 04:42 AM\n BUN:\n 40 mg/dL\n 04:42 AM\n Creatinine:\n 0.7 mg/dL\n 04:42 AM\n Glucose:\n 99 mg/dL\n 04:42 AM\n Hematocrit:\n 26.3 %\n 10:30 AM\n Finger Stick Glucose:\n 119\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU-6\n Transferred to: 211\n Date & time of Transfer: 1:15PM\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684976, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n HCT stable\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.3\nC (99.2\n HR: 85 (79 - 98) bpm\n BP: 121/75(85) {58/30(38) - 124/76(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 166 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 166 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,580 mL\n Urine:\n 1,480 mL\n 2,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -2,414 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n Gen: alert NAD sitting up\n HEENT: o/p clear\n CV: RR loud S2\n Chest: faint exp wheeze\n Abd: soft NT + BS\n Ext: no edema\n Neuro: alert\n Labs / Radiology\n 8.4 g/dL\n 301 K/uL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n 10:30 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n 26.3\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n 1. GI bleed: etiology unclear- upper source but could not localize\n ulceration - but could be hidden by clot etc. Stable HCT overnight, no\n hemodynamic instability Plan for rescope tomm or acutely if bleeds.\n Swicth to PPI\n 2. ? ECG changes in field, cycled CKs and trop and have been negative\n 3. DM: SSRI\n 4. COPD: Spiriva, Advair to start\n Remaing issues as per Housestaff notes - reviewed\n ICU Care\n Nutrition: ? clears\n Glycemic Control:\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: brother updated, wife coming into town in AM\n Code status: Full code\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 684931, "text": "Chief Complaint: GI bleed, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 53 yr old gentleman with HTN COPD DM type 2 developed abd pain nausea\n and vomiting 3 days PTA- dark black emesis and melena. he did not seek\n care until this AM, dizzy, called 911. En route ? elevations On\n arrival to ED STEMI actiavetd but repeat 12 lead without acute ECG\n changes.\n No cardiac hx. Initial trop 0.05 CK 28\n Vitals afebrile HR 99 BP 90/29 18 95% RA - pale. HCT 23.7 (no baseline)\n lactate 2.7 - wbc 20K normal plts and coags. NG lavage dark red, not\n clear with 300 CC saline\n Given 4L saline, started on 2 units PRBC, and GI called for urgent EGD\n then sent to MICU\n On arrival to MICU EGD w clot in fundus, no source identified - decent\n but incomplete visual so may need rescope\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n COPD/asthma\n PTX with bleb rupture\n DM2\n chronic knee pain obn oxycontin\n Home Meds: Metformin, Lisinopril, cholesterol med\n no CAD no GI bleed\n Occupation: owns a pizza shop in \n Drugs: neg\n Tobacco: active 2PPD\n Alcohol: denies but ? by PCP\n : married with 2 children\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, Tachycardia\n Gastrointestinal: Emesis, Diarrhea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Flowsheet Data as of 05:21 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 89 (85 - 97) bpm\n BP: 92/73(77) {58/30(38) - 109/73(77)} mmHg\n RR: 26 (21 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,801 mL\n PO:\n TF:\n IVF:\n 1,020 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 1,325 mL\n Urine:\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,476 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: no edema\n Skin: Warm\n Neurologic: Attentive, conversant\n Labs / Radiology\n 437\n 23.7\n 209\n 1.6\n 73\n 24\n 98\n 4.3\n 134\n 20.1\n [image002.jpg]\n Other labs: PT / PTT / INR://13/22/1.1, ALT / AST:/,\n Differential-Neuts:81, Band:0, Lymph:14, Ca++:8, Mg++:2, PO4:4.4\n ECG: sinus rhythm with normal axis j point in II,III, F no reciprocal\n changes\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n 1. GI bleed: etiology unclear- upper source but could not localize\n ulceration - but could be hidden by clot etc. we will transfuse cycle\n HCT q4-6, give another unit blood. PPI drip. repeat EGD in 24-48 hours\n or sooner. He has 2 lareg bore , move to cordis if\n hemodynamically unstable.\n 2. ? ECG changes in field, cycle cks, repeat ECG in AM, hold ASA,\n cannot get bblockers\n 3. DM: SSRI\n 4. Remaining issues as per Housestaff\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 16 Gauge - 03:59 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: with patient, wife is out of town\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684932, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n HCT stable\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.3\nC (99.2\n HR: 85 (79 - 98) bpm\n BP: 121/75(85) {58/30(38) - 124/76(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 166 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 166 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,580 mL\n Urine:\n 1,480 mL\n 2,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -2,414 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n Labs / Radiology\n 8.4 g/dL\n 301 K/uL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n 10:30 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n 26.3\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n 1. GI bleed: etiology unclear- upper source but could not localize\n ulceration - but could be hidden by clot etc. we will transfuse cycle\n HCT q4-6, give another unit blood. PPI drip. repeat EGD in 24-48 hours\n or sooner. He has 2 lareg bore , move to cordis if\n hemodynamically unstable.\n 2. ? ECG changes in field, cycle cks, repeat ECG in AM, hold ASA,\n cannot get bblockers\n 3. DM: SSRI\n 4. Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684934, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n HCT stable\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.3\nC (99.2\n HR: 85 (79 - 98) bpm\n BP: 121/75(85) {58/30(38) - 124/76(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 166 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 166 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,580 mL\n Urine:\n 1,480 mL\n 2,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -2,414 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 8.4 g/dL\n 301 K/uL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n 10:30 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n 26.3\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n 1. GI bleed: etiology unclear- upper source but could not localize\n ulceration - but could be hidden by clot etc. we will transfuse cycle\n HCT q4-6, give another unit blood. PPI drip. repeat EGD in 24-48 hours\n or sooner. He has 2 lareg bore , move to cordis if\n hemodynamically unstable.\n 2. ? ECG changes in field, cycled CKs and trop and have been negative\n 3. DM: SSRI\n 4. Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684935, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n HCT stable\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.3\nC (99.2\n HR: 85 (79 - 98) bpm\n BP: 121/75(85) {58/30(38) - 124/76(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 166 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 166 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,580 mL\n Urine:\n 1,480 mL\n 2,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -2,414 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n Gen: alert NAD sitting up\n HEENT: o/p clear\n CV: RR loud S2\n Chest: faint exp wheeze\n Abd: soft NT + BS\n Ext: no edema\n Neuro: alert\n Labs / Radiology\n 8.4 g/dL\n 301 K/uL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n 10:30 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n 26.3\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n 1. GI bleed: etiology unclear- upper source but could not localize\n ulceration - but could be hidden by clot etc. Stable HCT overnight, no\n hemodynamic instability\n 2. ? ECG changes in field, cycled CKs and trop and have been negative\n 3. DM: SSRI\n 4. COPD: Spiriva, Advair to start\n ICU Care\n Nutrition: ? clears\n Glycemic Control:\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: brother updated, wife coming into town in AM\n Code status: Full code\n Disposition: call out\n" }, { "category": "Nursing", "chartdate": "2187-07-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684812, "text": "TITLE:\n 53yo male with 3 day h/o weakness/fatigue with N/V x3 on Saturday,\n called EMS this AM as he was feeling extremely lightheaded and dizzy.\n Upon EMS arrival, pt hypotensive into 70s with EKG showing possible ST\n elevation so pt given 325mg ASA by EMS. On arrival to , pt extremely\n pale with HCT 23, guiac positive with h/o dark stool. NGT was placed\n with dark red/brown blood lavaged. 40mg IV protonix given, 4L IVF,\n 250mg erythryomycin, and 1 unit PRBCs hung. Pt seen by GI who will\n perform EDG upon arrival to ICU. Being transferred to ICU for further\n monitoring GIB.\n EGD performed by GI @ 1530 showing large amts old blood causing\n difficulty finding source of bleed. GI to re-scope tomorrow or\n Wednesday.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient had 1 melnotic stool in pm. Completed 3^rd unit of PrBC\n Action:\n Hct checked at hrs- hct 25.8( Goal -25 ). Repeat Hct at midnight\n 25.9\n Response:\n Hct at 4am 25.4\n Plan:\n Will continue monitoring. Hct q 6 hrs.\n" }, { "category": "Physician ", "chartdate": "2187-07-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684909, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 03:15 PM\n NASAL SWAB - At 08:32 PM\n - EGD no obvious source of bleeding. Clot in stomach easily moved and\n now source seen below. Plan to re-scope in 24-48hrs. IV PPI,\n transfuse to maintain crit.\n -2130: s/p 3units pRBC. Next Hct at 0000hrs.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Fentanyl - 03:20 PM\n Midazolam (Versed) - 03:40 PM\n Pantoprazole (Protonix) - 04:37 PM\n Insulin\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 88 (79 - 98) bpm\n BP: 111/68(79) {58/30(38) - 123/73(79)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,146 mL\n 65 mL\n PO:\n TF:\n IVF:\n 1,084 mL\n 65 mL\n Blood products:\n 562 mL\n Total out:\n 2,280 mL\n 2,030 mL\n Urine:\n 1,480 mL\n 2,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,866 mL\n -1,965 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, distant BS, no wheezes,\n rales, ronchi\n CV: Regular rate and rhythm, DISTANT S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 301 K/uL\n 8.4 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 105 mEq/L\n 141 mEq/L\n 25.4 %\n 9.8 K/uL\n [image002.jpg]\n 05:01 PM\n 08:02 PM\n 11:28 PM\n 04:42 AM\n WBC\n 11.5\n 9.8\n Hct\n 22.9\n 25.8\n 25.9\n 25.4\n Plt\n 291\n 301\n Cr\n 0.7\n TropT\n 0.03\n Glucose\n 99\n Other labs: PT / PTT / INR:13.2/22.5/1.1, CK / CKMB /\n Troponin-T:38/5/0.03, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 53yo M with HTN, DMII, COPD who presents\n with sub-acute upper GIB for four days with no visualization of active\n bleed on EGD. Hemodynamically stable.\n .\n # UGIB: No history of PUD, NSAID overuse, liver dz, or ETOH abuse. EGD\n showing significant clot in stomach with no active bleeding. S/p 4LNS\n in ED and s/p 2 units of blood with resolution of tachycardia and\n low-normal blood pressure (given Pts h/o HTN and having not taken Rx in\n 24hrs.).\n - Hemodynamically stable at present.\n - HCT stable throughout the night. TRANSFUSION GOAL 25 (given\n possibility of active bleeding),\n - IVF bolus PRN for hypotension and transfusion PRN\n - IV PPI drip\n - repeat EGD in 24-48 hrs\n - If decompensate, would consider tagged red cell scan\n - maintain two peripheral 16 gauge IVs\n .\n # HTN: Holding all outpt antiHTN given low-normal BP currently\n .\n # DMII: holding metformin given hypovolemia and elevated lactate at\n presentaion. SSI while inpt.\n # EKG abnl: As above, likely spurious tracing by EMS 12-lead, but also\n possibly rate related HR=127 in ambulance. Low suspicion for ACS.\n - 3 sets CE\n .\n # HLD: will try to determine outpt regimen\n .\n # Chronic pain: states currently does not need home oxycontin. would be\n reluctant given hypotension\n .\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin\n Lines:\n 16 Gauge - 03:59 PM\n 20 Gauge - 01:15 AM\n Prophylaxis:\n DVT: SCD\n Stress ulcer: IV PPI gtt\n VAP: n/a\n Comments:\n Communication: With Patient Comments:\n Code status: Full code\n Disposition: To floor if remains stable pending discussion with GI re :\n EGD today.\n" }, { "category": "Nursing", "chartdate": "2187-07-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685551, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n NGT to low continuous suction. Draining bilious. No blood seen.\n HCT stable this am.\n DSG CDI. No staining seen.\n Continues on Fent/Prop GTT for sedation.\n Vent set on CMV\n Action:\n NGT flushed X1 per primary team to slow drainage.\n Slow rate changes made to vent for wean.\n Response:\n No changes. Remains stable.\n Scant drainage noted from NGT after flush. Primary team aware.\n Plan:\n Continue to monitor NGT output amount and color.\n Wean to extubate in am. Pt listed as a challenging intubation but not\n difficult.\n" }, { "category": "Respiratory ", "chartdate": "2187-07-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685460, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n" }, { "category": "Respiratory ", "chartdate": "2187-07-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685461, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts\n" }, { "category": "General", "chartdate": "2187-07-26 00:00:00.000", "description": "ICU Event Note", "row_id": 685264, "text": "Clinician: Attending\n Arrest called on patient for hematemesis and HOTN:\n 53 yo man admitted with UGIB EGD found to have fungating mass. Was on\n medical , suddenly vomitted\n blood, HOTNsive briefly to 80s, tachy to 140s. Not chest compressions\n required. Patient transferred to MICU,\n where patient again HOTNsive to 70s. Trauma line placed. - patient\n cool, clammy, pale. NGT with continuous red\n blood from stomach. blood rapidly infused. Will aggressively\n transfusion fluid, blood, FFP, and platelets. Surgery consult - Dr.\n obtained, who will take patient emergently\n to the OR for gastrectomy\n Total time spent: 80 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2187-07-28 00:00:00.000", "description": "Intensivist Note", "row_id": 685526, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS.\n Chief complaint:\n Presented with hematemesis\n PMHx:\n HTN, DMII, COPD with home O2\n Current medications:\n Insulin 100 Units/100 ml NS @ 0-10 UNIT/HR IV DRIP TITRATE TO glucose <\n 150 and >60\n Fingersticks every hour\n Tacrolimus 1.5 mg PO Q12H\n Dose to be admin at 6pm and at 6am. Please give suspension\n form\n Mycophenolate Mofetil 1000 mg PO BID\n ValGANCIclovir Suspension 450 mg PO 2X/WEEK (TU,FR)\n Fluconazole 400 mg PO/NG Q24H\n HYDROmorphone (Dilaudid) 0.125-0.5 mg IV Q4H:PRN pain\n Pantoprazole 40 mg PO Q24H Start when tolerating PO\n Ondansetron 4 mg IV Q8H:PRN nausea/vomiting\n Prochlorperazine 5-10 mg IV Q6H:PRN nausea\n Docusate Sodium 100 mg PO/NG \n PredniSONE 20 mg PO DAILY\n POD #6 and ongoing\n Sulfameth/Trimethoprim Suspension 10 ml PO/NG DAILY\n Pantoprazole 40 mg IV Q24H\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN.\n 24 Hour Events:\n To OR emergently after large UGIB. Found to have gastric ca, underwent\n subtotal gastrectomy and Billroth II. Remained intubated and sedated.\n Transiently hypotensive with turning; responded well to boluses. No\n pressors. Fentanyl gtt for pain.\n Post operative day:\n POD#1 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:00 PM\n Cefazolin - 04:21 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 07:52 AM\n Pantoprazole (Protonix) - 09:19 AM\n Other medications:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.3\nC (99.1\n HR: 102 (100 - 132) bpm\n BP: 119/70(86) {54/38(45) - 145/79(97)} mmHg\n RR: 20 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.4 kg (admission): 89.4 kg\n CVP: 9 (3 - 11) mmHg\n Total In:\n 13,012 mL\n 1,317 mL\n PO:\n Tube feeding:\n IV Fluid:\n 11,669 mL\n 1,317 mL\n Blood products:\n 1,344 mL\n Total out:\n 2,967 mL\n 355 mL\n Urine:\n 987 mL\n 285 mL\n NG:\n 250 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 10,045 mL\n 962 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 650) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 29 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: 7.41/43/145/26/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable ) Air leak when tube deflated.\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: No(t) Rash: , (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 191 K/uL\n 9.9 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.8 %\n 17.8 K/uL\n [image002.jpg]\n 04:10 AM\n 04:21 AM\n 06:05 AM\n 07:36 AM\n 07:50 AM\n 02:08 PM\n 02:34 PM\n 11:58 PM\n 01:54 AM\n 03:31 AM\n WBC\n 21.4\n 30.1\n 23.3\n 17.8\n Hct\n 31.6\n 36\n 35\n 35.3\n 31.2\n 27.8\n Plt\n 200\n 240\n 183\n 191\n Creatinine\n 0.8\n 0.8\n 0.6\n TCO2\n 25\n 26\n 26\n 27\n 28\n 28\n Glucose\n 109\n 118\n 136\n 145\n 118\n Other labs: PT / PTT / INR:14.1/26.1/1.2, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:, Alk-Phos / T bili:30/0.4, Amylase /\n Lipase:48/, Lactic Acid:1.6 mmol/L, Albumin:2.3 g/dL, LDH:132 IU/L,\n Ca:7.4 mg/dL, Mg:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: PLAN: 53M with gastroadenocarcinoma and large UGIB\n s/p subtotal gastrectomy and Billroth II\n Neuro: Propofol for sedation.\n CVS: Not on pressors. Became transiently hypotensive with turns.\n Responded well to boluses. MAP>60\n Pulm: Remains intubated. Vent rate not changed due to pt's COPD status,\n likely retains CO2 normally. Change to PSV\n GI: Capped JT, NPO.. Inhalers as needed\n FEN: LR @150 . Would change to Maintenance\n Renal: Follow UOP\n Heme: Hct 31.2. Stable Hold HSQ. Endo: RISS\n ID: Kefzol/flagyl x 3 doses. Stomach was not perforated.\n TLD: NG to suction, JT, RIJ, Aline\n Wounds: Abd\n Imaging: None\n Prophylaxis: PPI\n Consults: GI, East\n Code: Full\n Disposition: SICU\n Consults: General surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Shock)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Triple Introducer - 11:00 PM\n Arterial Line - 07:25 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI. Change to H2\n VAP bundle: Elevate HOB, Chlorhexadine oral care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2187-07-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685345, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt arrived from floor s/p CODE BLE called after pt vomited large amt\n frank red blood, became acutely tachycardic and hypotensive but\n remained responsive. Received by this RN at 2300. ST 140-150\ns. Not\n requiring pressors. Initial SBP 140-150 but decreasing to ~100 prior\n to transfusions. Pt alert and oriented x 3.\n Action:\n NGT placed by MD\n Right IJ triple introducer placed\n placement confirmed by CXR\n 3 units PRBC up\n 3 liters LR up\n 1 unit FFP up\n Wife updated by MICU and surgery resident\n Response:\n 900 cc bright red blood out of NGT\n SBP 140 after fluid/product\n HR down to 120\n Pt shivering from fluid\n wrapped in warm blankets\n Wife to bedside\n Plan:\n Sent emergently to OR in care of anesthesia at 2400. Family given\n beeper by this RN. Wife updated by this RN after OR contact for\n brief update. ETA 0700.\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , MD\n on: 08:26 ------\n" }, { "category": "Nursing", "chartdate": "2187-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685609, "text": "53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt with NGT in place and to low wall suction. NGT putting out dark\n green bilious fluid. Abdomen is large but soft, hypoactive BS. AM HCT\n 25.9\n Action:\n Discussed HCT with Dr. . No new orders at present.\n Response:\n No change. HR remains 90s-100 and urine output adequate\n Plan:\n Follow NGT output, monitor HCT levels. Monitor for chages in VS\n Hypotension (not Shock)\n Assessment:\n Pt SBP running 90s-120s while at rest however pt\ns BP noted to drop\n into 70s/30s with suctioning.\n Action:\n Suction pt only as needed\n Response:\n Pt\ns BP recovered back to baseline without intervention\n Plan:\n Follow BP, Keep MAP > 60 . Phenylephrine if MAP falls below 60\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt without signs of pain\n Action:\n Continues on fentanyl drip for pain management\n Response:\n Pt stable\n Plan:\n Monitor pt for signs of pain, continue fentanyl drip for now\n" }, { "category": "Nursing", "chartdate": "2187-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685713, "text": " Problem\n S/P subtotal gastrectomy secondary to metastatic\n adenocarcinoma\n Assessment:\n In AM sedated on propfol\n Fentanyl gtt for pain control\n HR 80\ns NSR, ABP ~ 100/60\n One Unit of PRBC being administered\n Fluid balance + 15 liters\n Action:\n Weaned ventilator (7.40, 57, 88, 7, 37) and extubated\n HL IVF\n Lasix X1\n Trophic tube feeds started via j-tube\n Dr. spoke with patient\ns wife this morning\n Response:\n Post transfusion HCT 25.6 (25.9)\n No s+s of active bleeding\n Diuresing well, fluid balance MN\n 1700 negative 1500 cc\n Patient A+Ox3, states pain is tolerable\n Plan:\n Aggressive pulmonary toileting\n Pain control\n Monitor labs\n Patient and family support\n" }, { "category": "Physician ", "chartdate": "2187-07-29 00:00:00.000", "description": "Intensivist Note", "row_id": 685603, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Chief complaint:\n nausea\n PMHx:\n HTN, DMII, COPD with home O2, smoker\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS\n Continuous at 75 ml/hr12. Phenylephrine 0.5-3 mcg/kg/min IV DRIP\n TITRATE TO MAPS >60 Order date: @ 0329\n 4. Acetylcysteine 20% 3-5 mL NEB Q6H:PRN thick secretions 13.\n Potassium Chloride IV Sliding Scale 07/03\n 5. Calcium Gluconate IV Sliding Scale Order , Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale, Magnesium Sulfate IV Sliding Scale , Propofol\n 20-100 mcg/kg/min IV DRIP TITRATE TO sedation, Famotidine 20 mg IV\n Q12H , Sodium Phosphate IV Sliding Scale , Fentanyl Citrate 25-100\n mcg IV Q4H:PRN pain , Fentanyl Citrate 100-200 mcg/hr IV DRIP\n INFUSION\n 24 Hour Events:\n TRIPLE INTRODUCER - STOP 11:39 AM\n MULTI LUMEN - START 11:43 AM\n Tolerated CPAP w/ PS for several hours but became hypercarbic and\n acidotic with copius secretions. PLaced back on CMV airway peak\n pressures to the 40's. Responded to albuterol and suctioning.\n Post operative day:\n POD#2 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:21 AM\n Metronidazole - 06:05 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.7\nC (99.9\n HR: 95 (95 - 108) bpm\n BP: 98/54(68) {88/45(58) - 140/76(96)} mmHg\n RR: 20 (14 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.4 kg (admission): 89.4 kg\n CVP: 14 (8 - 20) mmHg\n Total In:\n 4,409 mL\n 623 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,379 mL\n 623 mL\n Blood products:\n Total out:\n 2,680 mL\n 670 mL\n Urine:\n 2,610 mL\n 670 mL\n NG:\n 70 mL\n Stool:\n Drains:\n Balance:\n 1,729 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 481 (399 - 505) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 41 cmH2O\n Plateau: 26 cmH2O\n Compliance: 41.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.25/76./96./32/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 162\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n bilat, Diminished: bilat), wet sounding\n Abdominal: Soft, dressing CDI\n Neurologic: Sedated\n Labs / Radiology\n 221 K/uL\n 8.9 g/dL\n 127 mg/dL\n 0.5 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 7 mg/dL\n 105 mEq/L\n 139 mEq/L\n 25.9 %\n 18.3 K/uL\n [image002.jpg]\n 06:05 AM\n 07:36 AM\n 07:50 AM\n 02:08 PM\n 02:34 PM\n 11:58 PM\n 01:54 AM\n 03:31 AM\n 01:46 AM\n 02:03 AM\n WBC\n 30.1\n 23.3\n 17.8\n 18.3\n Hct\n 35\n 35.3\n 31.2\n 27.8\n 25.9\n Plt\n 21\n Creatinine\n 0.8\n 0.8\n 0.6\n 0.5\n TCO2\n 26\n 26\n 27\n 28\n 28\n 35\n Glucose\n 118\n 136\n 145\n 118\n 127\n Other labs: PT / PTT / INR:14.1/26.1/1.2, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:, Alk-Phos / T bili:30/0.4, Amylase /\n Lipase:48/, Lactic Acid:1.6 mmol/L, Albumin:2.3 g/dL, LDH:132 IU/L,\n Ca:7.3 mg/dL, Mg:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 53M with gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II, intubated in ICU, failed vent\n wean \n Neurologic: Propofol for sedation\n Cardiovascular: Not on pressors. Became transiently hypotensive with\n turns + suction. MAP>60, phenylephrine dripordered if needed\n Pulmonary: Cont ETT, Tolerated CPAP w/ PS for several hours but became\n hypercarbic and acidotic with copius secretions. PLaced back on CMV\n airway peak pressures to the 40's. Responded to albuterol and\n suctioning, plan to wean and extubate if possible. CXR ordered.\n Gastrointestinal / Abdomen: Capped JT, NPO\n Nutrition: D5 + 20meq K@75\n Renal: pt w/ good U/O (100-300/hr) but remains largely net positive\n Hematology: following HCT\n Endocrine: RISS, RISS\n Infectious Disease: Kefzol/flagyl x 3 doses. Stomach was not perforated\n Lines / Tubes / Drains: NG to suction, JT, RIJ, Aline\n Wounds: abd wounds dressing C/D/I\n Imaging: CXR today, F/U today's CXR\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:25 AM\n 20 Gauge - 11:30 AM\n Multi Lumen - 11:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2187-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685605, "text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685714, "text": " Problem\n S/P subtotal gastrectomy secondary to metastatic\n adenocarcinoma\n Assessment:\n In AM sedated on propfol\n Fentanyl gtt for pain control\n HR 80\ns NSR, ABP ~ 100/60\n One Unit of PRBC being administered\n Fluid balance + 15 liters\n Action:\n Weaned ventilator (7.40, 57, 88, 7, 37) and extubated\n HL IVF\n Lasix X1\n Trophic tube feeds started via j-tube\n Dr. spoke with patient\ns wife this morning\n Response:\n Post transfusion HCT 25.6 (25.9)\n No s+s of active bleeding\n Diuresing well, fluid balance MN\n 1700 negative 1500 cc\n Patient A+Ox3, states pain is tolerable\n HR 90\ns-100 NSR/ST with ABP ~ 135/60\n Plan:\n Aggressive pulmonary toileting\n Pain control\n Monitor labs\n Patient and family support\n" }, { "category": "Physician ", "chartdate": "2187-07-28 00:00:00.000", "description": "Intensivist Note", "row_id": 685493, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS.\n Chief complaint:\n Presented with hematemesis\n PMHx:\n HTN, DMII, COPD with home O2\n Current medications:\n Insulin 100 Units/100 ml NS @ 0-10 UNIT/HR IV DRIP TITRATE TO glucose <\n 150 and >60\n Fingersticks every hour\n Tacrolimus 1.5 mg PO Q12H\n Dose to be admin at 6pm and at 6am. Please give suspension\n form\n Mycophenolate Mofetil 1000 mg PO BID\n ValGANCIclovir Suspension 450 mg PO 2X/WEEK (TU,FR)\n Fluconazole 400 mg PO/NG Q24H\n HYDROmorphone (Dilaudid) 0.125-0.5 mg IV Q4H:PRN pain\n Pantoprazole 40 mg PO Q24H Start when tolerating PO\n Ondansetron 4 mg IV Q8H:PRN nausea/vomiting\n Prochlorperazine 5-10 mg IV Q6H:PRN nausea\n Docusate Sodium 100 mg PO/NG \n PredniSONE 20 mg PO DAILY\n POD #6 and ongoing\n Sulfameth/Trimethoprim Suspension 10 ml PO/NG DAILY\n Pantoprazole 40 mg IV Q24H\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN.\n 24 Hour Events:\n To OR emergently after large UGIB. Found to have gastric ca, underwent\n subtotal gastrectomy and Billroth II. Remained intubated and sedated.\n Transiently hypotensive with turning; responded well to boluses. No\n pressors. Fentanyl gtt for pain.\n Post operative day:\n POD#1 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 10:00 PM\n Cefazolin - 04:21 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Propofol - 75 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 07:52 AM\n Pantoprazole (Protonix) - 09:19 AM\n Other medications:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.3\nC (99.1\n HR: 102 (100 - 132) bpm\n BP: 119/70(86) {54/38(45) - 145/79(97)} mmHg\n RR: 20 (0 - 25) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.4 kg (admission): 89.4 kg\n CVP: 9 (3 - 11) mmHg\n Total In:\n 13,012 mL\n 1,317 mL\n PO:\n Tube feeding:\n IV Fluid:\n 11,669 mL\n 1,317 mL\n Blood products:\n 1,344 mL\n Total out:\n 2,967 mL\n 355 mL\n Urine:\n 987 mL\n 285 mL\n NG:\n 250 mL\n 70 mL\n Stool:\n Drains:\n Balance:\n 10,045 mL\n 962 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 650) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 29 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: 7.41/43/145/26/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: No(t) Rash: , (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 191 K/uL\n 9.9 g/dL\n 118 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 12 mg/dL\n 107 mEq/L\n 138 mEq/L\n 27.8 %\n 17.8 K/uL\n [image002.jpg]\n 04:10 AM\n 04:21 AM\n 06:05 AM\n 07:36 AM\n 07:50 AM\n 02:08 PM\n 02:34 PM\n 11:58 PM\n 01:54 AM\n 03:31 AM\n WBC\n 21.4\n 30.1\n 23.3\n 17.8\n Hct\n 31.6\n 36\n 35\n 35.3\n 31.2\n 27.8\n Plt\n 200\n 240\n 183\n 191\n Creatinine\n 0.8\n 0.8\n 0.6\n TCO2\n 25\n 26\n 26\n 27\n 28\n 28\n Glucose\n 109\n 118\n 136\n 145\n 118\n Other labs: PT / PTT / INR:14.1/26.1/1.2, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:, Alk-Phos / T bili:30/0.4, Amylase /\n Lipase:48/, Lactic Acid:1.6 mmol/L, Albumin:2.3 g/dL, LDH:132 IU/L,\n Ca:7.4 mg/dL, Mg:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: PLAN: 53M with gastroadenocarcinoma and large UGIB\n s/p subtotal gastrectomy and Billroth II\n Neuro: Propofol for sedation.\n CVS: Not on pressors. Became transiently hypotensive with turns.\n Responded well to boluses. MAP>60\n Pulm: Remains intubated. Vent rate not changed due to pt's COPD status,\n likely retains CO2 normally.\n GI: Capped JT, NPO\n FEN: LR @150\n Renal: Follow UOP\n Heme: Hct 31.2. Stable Hold HSQ. Endo: RISS\n ID: Kefzol/flagyl x 3 doses. Stomach was not perforated.\n TLD: NG to suction, JT, RIJ, Aline\n Wounds: Abd\n Imaging: None\n Prophylaxis: PPI\n Consults: GI, East\n Code: Full\n Disposition: SICU\n Consults: General surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Shock)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Triple Introducer - 11:00 PM\n Arterial Line - 07:25 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: Elevate HOB, Chlorhexadine oral care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2187-07-30 00:00:00.000", "description": "Intensivist Note", "row_id": 685752, "text": "SICU\n HPI:\n 53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Chief complaint:\n LGIB\n PMHx:\n PMH: HTN, DMII, COPD with home O2, smoker\n Current medications:\n Acetylcysteine 20% 3-5 mL NEB Q6H:PRN thick secretions, Albuterol\n 0.083% Neb Soln 1 NEB IH Q2H:PRN sob , Calcium Gluconate IV Sliding\n Scale, Docusate Sodium (Liquid) 100 mg PO BID, Famotidine 20 mg IV Q12H\n , Fentanyl Citrate 25-100 mcg IV Q4H:PRN pain , Furosemide 10 mg IV\n ONCE, Insulin SC (per Insulin Flowsheet) Sliding Scale, Ipratropium\n Bromide Neb 1 NEB IH Q2H:PRN sob, Magnesium Sulfate IV Sliding Scale,\n Phenylephrine 0.5-3 mcg/kg/min IV DRIP TITRATE TO MAPS >60, Potassium\n Chloride IV Sliding Scale Order, Sodium Phosphate IV Sliding\n Scale,\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:26 PM\n EXTUBATION - At 02:27 PM\n EXTUBATION - At 02:27 PM\n : Tolerated CPAP w/ PS for several hours but became hypercarbic and\n acidotic with copius secretions. PLaced back on CMV airway peak\n pressures to the 40's. Responded to albuterol and suctioning.\n : lasix given, responded w/ 1L. Extubated.\n Post operative day:\n POD#3 - subtotal gastrectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:21 AM\n Metronidazole - 06:05 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:25 PM\n Famotidine (Pepcid) - 07:44 PM\n Fentanyl - 02:12 AM\n Other medications:\n Flowsheet Data as of 04:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 36.9\nC (98.4\n HR: 103 (80 - 121) bpm\n BP: 98/65(76) {88/50(63) - 182/74(99)} mmHg\n RR: 18 (11 - 24) insp/min\n SPO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97.5 kg (admission): 89.4 kg\n CVP: 13 (4 - 28) mmHg\n Total In:\n 2,149 mL\n 97 mL\n PO:\n Tube feeding:\n 143 mL\n 43 mL\n IV Fluid:\n 1,738 mL\n 54 mL\n Blood products:\n 248 mL\n Total out:\n 3,945 mL\n 90 mL\n Urine:\n 3,845 mL\n 90 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n -1,796 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 538 (538 - 538) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 24 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 92%\n ABG: 7.38/60/80./33/7\n Ve: 6.6 L/min\n PaO2 / FiO2: 114\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), (Distant heart\n sounds: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , No(t) Wheezes : , No(t) Crackles : , Rhonchorous : ,\n Diminished: bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace, 1+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace, 1+), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 268 K/uL\n 9.3 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 102 mEq/L\n 143 mEq/L\n 27.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:54 AM\n 03:31 AM\n 01:46 AM\n 02:03 AM\n 04:41 AM\n 10:27 AM\n 12:54 PM\n 02:09 PM\n 02:16 AM\n 02:39 AM\n WBC\n 17.8\n 18.3\n 12.3\n Hct\n 27.8\n 25.9\n 25.6\n 27.4\n Plt\n 191\n 221\n 268\n Creatinine\n 0.6\n 0.5\n 0.5\n TCO2\n 28\n 35\n 35\n 36\n 37\n 37\n Glucose\n 118\n 127\n 107\n Other labs: PT / PTT / INR:11.9/23.3/1.0, CK / CK-MB / Troponin\n T:35/5/0.05, ALT / AST:104/53, Alk-Phos / T bili:54/0.4, Amylase /\n Lipase:48/, Fibrinogen:591 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:2.3\n g/dL, LDH:132 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ACIDOSIS, RESPIRATORY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p Subtotal Gastrectomy, CANCER (MALIGNANT NEOPLASM), OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPOTENSION (NOT SHOCK),\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n Assessment and Plan: 53M with gastroadenocarcinoma and large UGIB s/p\n subtotal gastrectomy and Billroth II, intubated in ICU, failed vent\n wean \n Neurologic: Fent for pain control. Start PO pain.\n Cardiovascular: Not on pressors. Became transiently hypotensive with\n turns + suction. MAP>60, phenylephrine drip ordered if needed\n Pulmonary: Extubated POD2. Pulm toilet. Nebs. Will need OOB\n Gastrointestinal / Abdomen: NPO w/ trophic TF, ? sips\n Nutrition: Tube feeding, Trophic (10)\n Renal: Foley, Renal: pt w/ good U/O. Lasix given (1L). Cr 0.5. DC\n foley MN.\n Hematology: Heme: Hct Stable at 27.4\n Endocrine: RISS\n Infectious Disease: Kefzol/flagyl x 3 doses. Stomach was not\n perforated. WBC 12.3\n Lines / Tubes / Drains: Foley, JT, RIJ, Aline, PIV, foley (? DC)\n Wounds: Dry dressings\n Imaging:\n Fluids: D5 1/2 NS, Potassium Chloride, D5 + 20meq K@75, TF@10\n Consults: General surgery, GI\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:45 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 07:25 AM\n 20 Gauge - 11:30 AM\n Multi Lumen - 11:43 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685753, "text": "53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with midline abdominal incision from tumor resection. Dressing\n intact as incision putting out only small amounts of serous drainage\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685754, "text": "53M developed dizzyness with nausea, stomach pain, and vomiting \n days prior to admission. Emesis was dark black. Melanotic stools began\n on saturday and continued for three days until admission. This morning\n dizzyness and weakness progressed, he called 911 and was brought to ED\n by EMS. Went to OR and found to have gastric Ca w/ mets, S/p Billroth 2\n resection.\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with midline abdominal incision from tumor resection. Dressing\n intact as incision putting out only small amounts of serous drainage\n HCT remains stable at 27.4 this AM\n Pt extubated yesterday. ABG at baseline. LS rhonchourous and pt having\n difficult time raising up sputum with cough\n Pt afebrile\n Action:\n Albuterol/atrovent nebulizers given. CPT done to help pt clear\n secretions\n Response:\n Pt able to raise more secretions with pulmonary toiler\n Plan:\n Continue CPT as needed, nebulizers as needed. Abdominal assessments\n every 4 hours and PRN\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt\ns fentanyl drip weaned to off. BP elevated into 180s and pt\n transiently tachycardic with elevated pain\n Action:\n Pt getting intermittent bolus dosing of fentanyl\n Response:\n Pt reports adequate pain relief\n Plan:\n Monitor pain level, medicate PRN\n" }, { "category": "Nursing", "chartdate": "2187-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685845, "text": "Pneumonia, other\n Assessment:\n RR 30-40\ns labored. Sats 85 on 70% face tent. Diaphoretic. Ls dim.\n Bilat.\n CXR from shows RLL pna.\n Action:\n Neb TX given\n Placed on 100% NRB.\n Sicu resident , MD notified.\n Enc to CDB/ Bilat CPT\n CTA ordered and completed.\n Response:\n Sats slowly recovered to 100%. RR down 18-24. LS clear with dim bases.\n Switched back to Face tent 70%. Sats slowly started to drop down again\n to 87-88%. Without an increase in RR.\n 4L NC placed in addition to 70% face tent. Abg\ns drawn. 7.45/50/67/36\n Slowly weaned down to 50% w/ 3LNC.\n Plan:\n Monitor resp status. Nebs As needed.\n Aggressive pulm toileting.\n Enc CDB.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/O mild pain w/ activity.\n However weak cough w/ splinting.\n Action:\n Given 1mg IVP Dilaudid x1 and PCA started.\n Response:\n Continues to deny pain even w/ coughing. Cough remains weak/\n non-productive.\n Using PCA adequately\n Plan:\n Continue to monitor Pain and enc PCA use so able to have a stronger\n cough.\n Monitor RR rate.\n" }, { "category": "ECG", "chartdate": "2187-07-26 00:00:00.000", "description": "Report", "row_id": 202394, "text": "Probable sinus tachycardia, rate 163. Vertical axis. Inferior and lateral\nST segment elevation raises question of inferolateral injury current but\nthis may be an effect of tachycardia. Probable left atrial abnormality.\nVertical axis. Non-diagnostic inferior Q waves. Cannot exclude inferior\nmyocardial infarction of indeterminate age. Compared to the previous tracing\nof the sinus rate has increased from 99 to 163 and repolarization\nchanges are more pronounced, probably an effect of sinus tachycardia.\n\n" }, { "category": "ECG", "chartdate": "2187-07-24 00:00:00.000", "description": "Report", "row_id": 202395, "text": "Sinus rhythm with slight sinus arrhythmia at the upper rate limit for normal.\nIncomplete right bundle-branch block pattern. Small Q waves in the\ninferolateral leads, raising the possibility of prior inferolateral or\ninferoapical myocardial infarction. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-30 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1087031, "text": " 8:43 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: clot\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with poor pulmonary status\n REASON FOR THIS EXAMINATION:\n clot\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc MON 4:22 PM\n PFI: No DVT is seen in either lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with poor pulmonary status. Here to assess for\n DVT.\n\n COMPARISON: None available.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler\n son exams were performed over bilateral common femoral, superficial\n femoral, and popliteal veins. The study demonstrates normal flow, respiratory\n variation, compressibility, and augmentation. No intraluminal thrombus is\n seen. Normal compressibility and color flow is also demonstrated in the calf\n veins bilaterally. Note is made of subcutaneous soft tissue edema extending\n posteromedially along the lower thighs as well as along the posterior\n popliteal regions, bilaterally.\n\n IMPRESSION: No DVT is seen in either lower extremity. Subcutaneous soft\n tissue edema.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-30 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1087032, "text": ", E. SICU-A 8:43 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: clot\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with poor pulmonary status\n REASON FOR THIS EXAMINATION:\n clot\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT is seen in either lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1086852, "text": " 1:00 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: changed over wire to TLC, assess for line placement and\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with COPD\n REASON FOR THIS EXAMINATION:\n changed over wire to TLC, assess for line placement and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE LINE PLACEMENT, .\n\n CLINICAL INFORMATION: Line changed over a wire.\n\n FINDINGS:\n\n The Cordis has been removed and replaced to a small-bore catheter in the right\n internal jugular. The tip terminates in the superior vena cava. Endotracheal\n tube terminates at the thoracic inlet. Otherwise, heart and mediastinum are\n within normal limits, and lungs are grossly clear. The right costophrenic\n angle has been omitted from the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086295, "text": " 11:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n eval for PNA, PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old with hypotension. Evaluate for pneumonia,\n pneumothorax.\n\n Single AP chest radiograph interpreted without comparison shows clear lungs.\n The heart, mediastinum, hila, and pulmonary vascularity are normal. There is\n no pleural effusion or pneumothorax.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1086719, "text": " 11:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? line placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new line placed\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Line placement.\n\n One portable view. Comparison with . The lungs remain clear. The\n heart and mediastinal structures are unremarkable. A right internal jugular\n sheath has been inserted and terminates the chest at the level of the upper\n superior vena cava.\n\n IMPRESSION:\n Line placement as described.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086922, "text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumonia, CHF, pt with increasing ventilatory requirements\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with COPD, intubated for upper GI bleed, gastric CA\n REASON FOR THIS EXAMINATION:\n ?pneumonia, CHF, pt with increasing ventilatory requirements and secretions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Pneumonia, increasing ventilatory requirements.\n\n FINDINGS:\n\n Comparison is made to the prior study from . The right IJ catheter\n terminates in the superior vena cava. Endotracheal tube terminates in the\n thoracic inlet. There is a patchy airspace opacity developing in the right\n lower lobes consistent with pneumonia. The remainder of the lungs are clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-30 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1087121, "text": " 4:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with gastroadenocarcinoma and large UGIB s/p subtotal\n gastrectomy and Billroth II\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KYg MON 6:55 PM\n PFI:\n\n 1. No PE.\n\n 2. New scattered foci of ground-glass attenuation with mild associated septal\n thickening which may represent asymmetric edema versus infection and less\n likely atypical distribution of aspiration.\n\n 3. New small bilateral pleural effusion and adjacent atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with gastroadenocarcinoma and large upper GI\n bleed status post subtotal gastrectomy and Billroth II. Evaluate for\n pulmonary embolus.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast and contrast-enhanced MDCT-acquired axial images of\n the chest from the thoracic inlet to the upper abdomen. The contrast-enhanced\n portion of the exam was repeated as there was suboptimal opacification of the\n pulmonary arteries on first attempt.\n\n FINDINGS: No filling defect is identified in the pulmonary arteries. The\n thoracic aorta maintains a normal caliber and contour. There is mild\n atherosclerotic calcification of the aortic arch and origin of the left\n subclavian artery. The heart size is normal. Mild aortic valvular\n calcification is of undetermined hemodynamic significance. The coronary\n arteries are calcified. Right IJ central venous catheter terminates in the\n SVC.\n\n The central airways are patent. Note is made of a saber-sheath configuration\n of the trachea compatible with COPD. There is mild bronchial wall dilatation\n and wall thickening. Minimal secretion is noted in the left upper lobe\n bronchus.\n\n There are new scattered foci of ground-glass attenuation in the apical segment\n of the right upper, apical posterior segment of the left upper lobe, and in\n the anterior aspects of the right middle lobe and lingula. Given associated\n mild septal thickening in the regions of abnormality, the findings may be due\n (Over)\n\n 4:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to asymmetric edema. Other diagnostic consideration include infection or less\n likely atypical distribution of aspiration.\n\n Small layering non- hemorrhagic pleural effusions and adjacent atelectasis is\n new. Scattered subcentimeter mediastinal and hilar lymph nodes are slightly\n increased in size from and may be reactive.\n\n This exam is not designed for subdiaphragmatic evaluation except to note post-\n operative changes related to gastrectomy. Subcentimeter hypodensity in the\n left lobe of the liver is stable and remains indeterminate. There are no\n lesions worrisome for osseous metastases.\n\n IMPRESSION:\n\n 1. No pulmonary embolus.\n\n 2. New scattered foci of ground-glass attenuation. Given mild septal\n thickening in the region of ground-glass, these findings may represent\n asymmetric edema. Other diagnostic consideration include an infectious/\n inflammatory etiology or less likely atypical distribution of aspiration.\n\n 3. New small bilateral pleural effusions and adjacent atelectasis.\n\n 4. Saber-sheath configuration of the trachea compatible with underlying COPD.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-30 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1087122, "text": ", E. SICU-A 4:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with gastroadenocarcinoma and large UGIB s/p subtotal\n gastrectomy and Billroth II\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. No PE.\n\n 2. New scattered foci of ground-glass attenuation with mild associated septal\n thickening which may represent asymmetric edema versus infection and less\n likely atypical distribution of aspiration.\n\n 3. New small bilateral pleural effusion and adjacent atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-26 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1086676, "text": " 3:16 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: Any metastatic lesions?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with UGIB and gastric mass on EGD.\n REASON FOR THIS EXAMINATION:\n Any metastatic lesions?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:01 PM\n - no metastatic disease in the chest\n - indeterminant 8mm left hepatic lobe lesion\n - enlarged perigastric lymph nodes and a prominent hepatogastric lymph node\n - known gastric mass not well visualized on CT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with upper GI bleed and gastric mass on endoscopy.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet through\n the pubic symphysis after administration of intravenous contrast. Multiplanar\n coronal and sagittal reformatted images were generated.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The lungs are clear. No pulmonary masses\n or nodules are identified. There is no pleural effusion or pericardial\n effusion. Coronary artery calcifications are noted. The thoracic aorta is\n normal in caliber. The central pulmonary arteries opacify normally, without\n central PE. The airways are patent bilaterally to the subsegmental level.\n There is no mediastinal, hilar or axillary lymphadenopathy.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The gastric body mass described on the\n EGD report is not well appreciated on CT. There are multiple enlarged lymph\n nodes adjacent to the anterior gastric body, measuring up to 11 mm. A\n prominent hepatogastric lymph node measures 15 mm x 10 mm (3:54).\n\n A hypoattenuating 8-mm hepatic lesion in segment II/ is too small to\n characterize. There is no intra- or extra-hepatic ductal dilation. The\n gallbladder, spleen, pancreas, adrenals are normal. The kidneys enhance\n symmetrically with prompt excretion of intravenous contrast.\n\n The small bowel is nondilated. There is no free fluid or free air in the\n abdomen.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The colon is normal in caliber. Oral\n contrast has passed through the small bowel and colon to the rectum. There\n are sigmoid diverticuli, without evidence for diverticulitis. There is no\n free pelvic fluid. No enlarged pelvic or inguinal lymph nodes are identified.\n There are small bilateral fat-containing inguinal hernias. The prostate is\n (Over)\n\n 3:16 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: Any metastatic lesions?\n Admitting Diagnosis: UPPER GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n enlarged, measuring 6 cm. Seminal vesicles are within normal limits.\n\n There are no bone lesions suspicious for malignancy.\n\n IMPRESSION:\n 1. No evidence metastatic disease in the chest.\n 2. Known mass in the body of the stomach.\n 3. Indeterminate 8mm segment II/ left hepatic lobe lesion.\n 4. Enlarged perigastric lymph nodes, and a prominent hepatogastric lymph\n node.\n 5. Coronary artery calcifications.\n 6. Sigmoid diverticulosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1087177, "text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PE, PNA\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man w/ gastroadenocarcinoma and large UGIB s/p subtotal gastrectomy\n and Billroth II\n REASON FOR THIS EXAMINATION:\n ? PE, PNA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with gastroadenocarcinoma after\n subtotal gastrectomy and Billroth II.\n\n Portable AP chest radiograph was compared to .\n\n The right internal jugular line tip is at the level of mid SVC. The\n cardiomediastinal silhouette is stable. Bibasilar atelectases have slightly\n improved in the interim. Upper lungs are clear and lungs are overall\n hyperinflated, most likely due to presence of emphysema. There is no\n appreciable pleural effusion or pneumothorax.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2104-04-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1182270, "text": " 2:50 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, eval for ptx and effu\n Admitting Diagnosis: CHEST PAIN;RULE OUT CORONARY ARTERY DISEASE\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, eval for ptx and effusions. icu provider\n is - page him if there is concern with findings\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old man, status post AVR/CABG. On fast track extubation.\n Assess for pneumothorax or pleural effusion.\n\n COMPARISON: Pre-op chest radiograph on .\n\n SINGLE FRONTAL CHEST RADIOGRAPH: The endotracheal tube terminates\n approximately 5.7 cm above the carina. The NG tube is in the stomach. The\n Swan-Ganz catheter via right IJ approach terminates in the right pulmonary\n artery. Lung volumes are low, with bihilar hazy opacities compatible with\n perioperative pulmonary congestion/edema. There is no pneumothorax or\n right-sided pleural effusion. Blunting of the left costophrenic angle is\n compatible with small pleural effusion and atelectasis. The cardiac size\n remains within normal limits. Median sternotomy wires are intact. A left\n chest tube terminates in the lateral base. A mediastinal tube terminates in\n the mid mediastinum. An external pacer is seen in the right upper quadrant.\n\n IMPRESSION: No pneumothorax. Mild-to-moderate pulmonary edema/congestion.\n Support devices in standard positions.\n\n" }, { "category": "Radiology", "chartdate": "2104-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1182543, "text": " 7:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CHEST PAIN;RULE OUT CORONARY ARTERY DISEASE\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, chest tube removal, rule out pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated. There is no evidence of pneumothorax.\n\n Unchanged lung volumes, mild-to-moderate left and right pleural effusions with\n subsequent areas of atelectasis. No pulmonary edema. No newly appeared\n parenchymal opacities. Right internal jugular vein introduction sheath in\n unchanged position.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-04-12 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1181900, "text": " 4:31 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN;RULE OUT CORONARY ARTERY DISEASE\\LEFT HEART CATH\n Admitting Diagnosis: CHEST PAIN;RULE OUT CORONARY ARTERY DISEASE\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with 3VD going for CABG\n REASON FOR THIS EXAMINATION:\n preop w/u for CABG\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Chest pain, rule out coronary artery disease.\n\n Two views. The lungs are clear except for minimal streaky density at the lung\n bases consistent with subsegmental atelectasis or scarring. The heart is\n within normal limits in size. The aorta is mildly tortuous. Mediastinal\n structures are otherwise unremarkable. The bony thorax is grossly intact.\n\n IMPRESSION: No active disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-04-14 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1182027, "text": " 9:11 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: eval for occlusion\n Admitting Diagnosis: CHEST PAIN;RULE OUT CORONARY ARTERY DISEASE\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with 3-vessel disease on cath, pre-op for CABG\n REASON FOR THIS EXAMINATION:\n eval for occlusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old gentleman with coronary artery disease. Preop CABG.\n\n TECHNIQUE: Evaluation of the bilateral extracranial carotid arteries was\n performed with grayscale, color and spectral Doppler ultrasound.\n\n FINDINGS: A mild amount of heterogeneous plaque was seen in the bilateral\n internal carotid arteries as well as in the left common carotid artery.\n\n On the right side peak systolic velocities were 70 cm/sec for the internal\n carotid artery, 73 cm/sec for the common carotid artery and 89 cm/sec for the\n external carotid artery. The right ICA/CCA ratio was 0.95.\n\n On the left side peak systolic velocities were 75 cm/sec for the ICA, 63\n cm/sec for the CCA and 93 cm/sec for the ECA. The left ICA/CCA ratio was 1.1.\n\n Both vertebral arteries presented antegrade flow.\n\n COMPARISON: None available.\n\n IMPRESSION: Less than 40% stenosis of the bilateral extracranial internal\n carotid arteries.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-04-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1182972, "text": " 2:29 PM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: CHEST PAIN;RULE OUT CORONARY ARTERY DISEASE\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CABG/AVR\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS \n\n CLINICAL INFORMATION: Question interval change, valve replacement.\n\n FINDINGS:\n\n Two views of the chest compared to prior study from . There is left\n lower lobe atelectasis, relatively unchanged, with small left-sided pleural\n effusion and very small right-sided pleural effusion. Remainder of lungs are\n clear. Heart and mediastinum within normal limits given recent post-operative\n changes.\n\n\n" }, { "category": "Echo", "chartdate": "2104-04-15 00:00:00.000", "description": "Report", "row_id": 75953, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Chest pain. Coronary artery disease. Shortness of breath.\nHeight: (in) 70\nWeight (lb): 183\nBSA (m2): 2.01 m2\nBP (mm Hg): 180/80\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 10:48\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the body\nof the LAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast\nin the body of the RA. No ASD by 2D or color Doppler. Prominent Eustachian\nvalve (normal variant).\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Mild regional LV systolic dysfunction. Low normal LVEF. No LV\nmass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Normal descending aorta diameter.\nComplex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). Moderate (2+) AR. AR vena contracta is >0.6cm.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS.\nPhysiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage. No spontaneous echo contrast is seen in the\nbody of the right atrium. No atrial septal defect or PFO is seen by 2D or\ncolor Doppler.\nThere is mild symmetric left ventricular hypertrophy.\nOverall left ventricular systolic function is (LVEF= 45 to 55%). No masses or\nthrombi are seen in the left ventricle.\nRight ventricular chamber size and free wall motion are normal.\nThere are complex atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. The aortic valve leaflets (3) are\nmildly thickened. Moderate (2+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse.\nPhysiologic mitral regurgitation is seen (within normal limits).\nThere is no pericardial effusion.\nDr. was notified in person of the results at the start of the case.\n\nPOST BYPASS:\nNormal RV systolic function.\nOverall LVEF 45%.\nIntact thoracic aorta.\nThe aortic bioprosthesis is intact, stable and functioning well with\ntransaortic prosthesis gradients peak 15 and mean 7 mm of Hg.\nTrivial TR. Previously hypokinetic basal inferior and inferoseptal persist.\n\n\n" }, { "category": "Echo", "chartdate": "2104-04-12 00:00:00.000", "description": "Report", "row_id": 75954, "text": "PATIENT/TEST INFORMATION:\nIndication: Preoperative assessment CABG.\nHeight: (in) 68\nWeight (lb): 183\nBSA (m2): 1.97 m2\nBP (mm Hg): 160/71\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 15:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional\nLV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Moderate (2+)\nAR. Eccentric AR jet directed toward the anterior mitral leaflet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is moderate regional left\nventricular systolic dysfunction with inferior and inferolateral akinesis. The\nremaining segments contract normally (LVEF = 35%). Right ventricular chamber\nsize and free wall motion are normal. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. Moderate (2+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD.\nModerate aortic regurgitation. Mild mitral regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2104-04-15 00:00:00.000", "description": "Report", "row_id": 187436, "text": "Sinus rhythm with slowing of the rate as compared to the previous tracing\nof . There is now intraventricular conduction delay of left\nbundle-branch block type. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2104-04-11 00:00:00.000", "description": "Report", "row_id": 187437, "text": "Sinus rhythm. A-V conduction delay. Delayed precordial R wave progression.\nLeft ventricular hypertrophy. Compared to the previous tracing of \nthe findings are similar.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2147-04-20 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1132510, "text": " 11:13 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: evaluate for stroke\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with left sided weakness\n REASON FOR THIS EXAMINATION:\n evaluate for stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old male with left-sided weakness.\n\n COMPARISON: CT of the head, and non-contrast head CT from\n , uploaded into PACS for reference\n only.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n without administration of IV gadolinium. Diffusion-weighted imaging, ADC map\n and fractional anisotropy imaging were also acquired.\n\n FINDINGS: Increased FLAIR signal of the posterior limb of the right internal\n capsule extending to involve the posterior caudate nucleus and putamen with\n corresponding diffusion restriction is consistent with acute to early subacute\n infarct. There is no intracranial hemorrhage, edema, or shift of midline\n structures. The ventricles and cerebral sulci are normal in size and\n configuration. Basal cisterns are preserved.\n\n There is a mucous retention cyst of the right anterior maxillary sinus, and\n mucosal thickening of the ethmoid air cells, frontal sinuses and fluid levels\n in the sphenoid sinuses. The mastoid air cells are clear.\n\n IMPRESSION:\n 1. Acute to early subacute infarct of the posterior limb of the right\n internal capsule, extending into the posterior caudate nucleus and putamen.\n Discussed by Dr. with Dr. on at 3 p.m.\n 2. Pansinus disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-04-20 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1132444, "text": " 2:25 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: LT SIDED WEAKNESS\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with L sided weakness\n REASON FOR THIS EXAMINATION:\n ? stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CTA head and neck following administration of intravenous\n contrast and perfusion.\n\n TECHNIQUE: Multiplanar CTA of the head and neck was performed with and\n without intravenous contrast administration. Additional 3D reconstructed\n images of the intra- and extra-cranial arterial vasculature were obtained.\n Additional perfusion images were performed.\n\n COMPARISON: Outside CT head .\n\n FINDINGS:\n\n NON-CONTRAST CT HEAD: There has been no significant interval evolution over\n approximately a 3/2 hour time interval of the ill-defined hypodensities within\n the right centrum semiovale, right lentiform nucleus, and right subinsular\n cortex. The remaining -white matter differentiation is otherwise\n preserved. There is mild hypoattenuation of the periventricular and deep\n subcortical white matter. The ventricles and cortical sulci are normal in\n size and configuration without evidence of mass effect or shift of the\n normally midline structures. There is no evidence of intra- or extra-axial\n hemorrhage. There are mucus retention cysts or polyps within both maxillary\n sinuses. There is opacification involving multiple bilateral ethmoid air\n cells, the sphenoid sinuses, and the frontal sinuses. The mastoid air cells\n and middle ear cavities are well aerated.\n\n CTA HEAD: The right vertebral artery is dominant. The right posterior\n communicating artery is hypoplastic. The left posterior communicating artery\n is visualized. There is mild narrowing involving the mid-to-distal M1 segment\n of the right MCA. The remaining intracranial arterial vasculature is within\n normal limits. There is no evidence of aneurysm or arteriovenous\n malformation.\n\n CT PERFUSION: The perfusion images are nondiagnostic secondary to technical\n failure.\n\n CTA NECK: The great vessel origins at the level of the aortic arch are within\n normal limits. The vertebral artery origins are patent. The paired vertebral\n arteries are normal in course and caliber without evidence of occlusion,\n flow-limiting stenosis, or dissection.\n\n (Over)\n\n 2:25 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: LT SIDED WEAKNESS\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The common, internal, and external carotid arteries are normal in course and\n caliber without evidence of occlusion, flow-limiting stenosis, or dissection.\n\n Cross-sectional analysis of the internal carotid arteries is as follows:\n\n On the right: Proximal DMIN 7.0 mm; distal DMIN 4.2 mm.\n\n On the left: Proximal DMIN 5.8 mm; distal DMIN 4.0 mm.\n\n The lung apices are clear. The airway is patent. The thyroid gland\n demonstrates homogeneous attenuation. There are no osseous lytic or blastic\n lesions identified.\n\n IMPRESSION:\n\n 1. Hypodensities of indeterminate age in the right centrum semiovale, right\n subinsular cortex, and right lentiform nucleus with mild narrowing of the mid\n to distal right M1 segment, which may be secondary to intrinsic disease or\n thrombus. Recommend MRI for further evaluation of acute infarction.\n\n 2. Pansinus disease as described above, the activity of which is to be\n determined clinically.\n\n 3. No CT evidence of aneurysm, dissection, or arteriovenous malformation.\n\n" }, { "category": "Radiology", "chartdate": "2147-04-20 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1132524, "text": " 12:44 PM\n RENAL U.S. PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: evaluate for renal artery stenosis\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hypertension\n REASON FOR THIS EXAMINATION:\n evaluate for renal artery stenosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 3:52 PM\n No evidence of renal artery stenosis on ultrasound.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old man with hypertension.\n\n Evaluate for renal artery stenosis.\n\n TECHNIQUE: Renal ultrasound with Doppler.\n\n COMPARISON: No prior.\n\n FINDINGS: The right kidney measures 11.1 cm. Left kidney measures 10.7 cm.\n There is no evidence of hydronephrosis or hydroureter. The RI indices in the\n right kidney measures 0.4 in the upper portion of the kidney, 0.5 in the mid,\n and 0.6 in the lower, with RI in the main renal artery of 0.6. The waveforms\n in the renal artery are within normal limits. The waveform in the renal vein\n appears normal.\n\n The RI indices of the arteries in the left kidney measures 0.5 in the upper\n portion, 0.5 in the mid, and 0.6 in the lower portion of the left kidney. The\n RI indices of the left main renal artery measures 0.64. The waveform in the\n renal vein on the left is within normal limits.\n\n IMPRESSION:\n 1. No evidence of hydronephrosis, or renal stone.\n 2. No evidence of renal artery stenosis bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-04-20 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1132525, "text": ", NMED TSICU 12:44 PM\n RENAL U.S. PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: evaluate for renal artery stenosis\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with hypertension\n REASON FOR THIS EXAMINATION:\n evaluate for renal artery stenosis\n ______________________________________________________________________________\n PFI REPORT\n No evidence of renal artery stenosis on ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2147-04-20 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1132523, "text": " 12:44 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: CVA\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with stroke\n REASON FOR THIS EXAMINATION:\n stenosis?\n ______________________________________________________________________________\n FINAL REPORT\n\n Standard Report Carotid US\n\n Study: Carotid Series Complete\n\n Reason: 35 year old s/p CVA\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right and the left there is no plaque seen.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 69/30, 51/23, 51/23 cm/sec. CCA peak systolic\n velocity is 86 cm/sec. ECA peak systolic velocity is 74 cm/sec. The ICA/CCA\n ratio is .8. These findings are consistent with no stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 83/28, 58/27, 57/28 cm/sec. CCA peak systolic velocity\n is 109 cm/sec. ECA peak systolic velocity is 100 cm/sec. The ICA/CCA ratio is\n .76. These findings are consistent with no stenosis.\n\n Right vertebral antegrade artery flow.\n Left vertebral antegrade artery flow.\n\n Impression: Right ICA no stenosis.\n Left ICA no stenosis.\n\n" }, { "category": "Echo", "chartdate": "2147-04-24 00:00:00.000", "description": "Report", "row_id": 90856, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular accident.\nHeight: (in) 66\nWeight (lb): 210\nBSA (m2): 2.04 m2\nBP (mm Hg): 188/90\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 12:04\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast or\nthrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD or PFO by\n2D, color Doppler or saline contrast with maneuvers. Prominent Eustachian\nvalve (normal variant).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Apically displaced papillary muscle (normal variant).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve. Normal mitral valve supporting structures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an\nantisialogogue prior to TEE probe insertion. No TEE related complications.\nContrast study was performed with 3 iv injections of 8 ccs of agitated normal\nsaline, at rest, with cough and post-Valsalva maneuver. Echocardiographic\nresults were reviewed by telephone with the houseofficer caring for the\npatient. MD caring for the patient was notified of the echocardiographic\nresults by e-mail.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No spontaneous\necho contrast or thrombus is seen in the body of the left atrium/left atrial\nappendage or the body of the right atrium/right atrial appendage. No atrial\nseptal defect or patent foramen ovale is seen by 2D, color Doppler or saline\ncontrast with maneuvers (though prominent inflow from the inferior vena cava\ndirected towards the interatrial septum by the Eustachian valve seems to blunt\nthe amount of superior vena caval inflow that comes in contact with the\ninteratrial septum). There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and global systolic function (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque to 40 cm from the incisors. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve. No\nvegetation/mass is seen on the pulmonic valve.\n\nIMPRESSION: No cardiac source of embolism. No evidence of atrial septal defect\nor patent foramen ovale with saline contrast and maneuvers. No significant\nvalvular abnormality. Normal thoracic aorta to 40 cm from the incisors.\n\nIf exclusion of a PFO is a clinical necessity, injection of saline via a\nfemoral vein might help to completely exclude a PFO.\n\nDr. was notified by pager on at 11:45am.\n\n\n" }, { "category": "Echo", "chartdate": "2147-04-21 00:00:00.000", "description": "Report", "row_id": 90857, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA./stroke\nHeight: (in) 66\nWeight (lb): 210\nBSA (m2): 2.04 m2\nBP (mm Hg): 164/108\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 14:41\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF 60%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nroot is mildly dilated at the sinus level. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2147-04-20 00:00:00.000", "description": "Report", "row_id": 229500, "text": "Sinus rhythm. Prominent mid-precordial voltage. Probably normal tracing for\nage. Since the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2147-04-20 00:00:00.000", "description": "Report", "row_id": 229501, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2171-05-28 00:00:00.000", "description": "Report", "row_id": 281604, "text": "Sinus rhythm. Since the previous tracing of no change in previously\ndescribed findings.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2171-05-29 00:00:00.000", "description": "Report", "row_id": 285131, "text": "Sinus rhythm. Since the previous tracing T waves may be somewhat less peaked.\nOtherwise, no change.\nTRACING #2\n\n" } ]

[ { "category": "Echo", "chartdate": "2102-03-15 00:00:00.000", "description": "Report", "row_id": 76630, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA. Dilated cardiomyopathy. Left ventricular function.\nHeight: (in) 66\nWeight (lb): 160\nBSA (m2): 1.82 m2\nBP (mm Hg): 126/95\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:30\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. Cannot exclude LV mass/thrombus. Transmitral Doppler\nand TVI c/w Grade III/IV (severe) LV diastolic dysfunction. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. Abnormal\ndiastolic septal motion/position consistent with RV volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The right atrium is moderately dilated. The\nestimated right atrial pressure is 10-20mmHg. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nThere is severe global left ventricular hypokinesis (LVEF = %). A left\nventricular mass/thrombus cannot be excluded. Transmitral Doppler and tissue\nvelocity imaging are consistent with Grade III/IV (severe) LV diastolic\ndysfunction. The right ventricular cavity is mildly dilated with depressed\nfree wall contractility. There is abnormal diastolic septal motion/position\nconsistent with right ventricular volume overload. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. Mild to moderate (+) mitral regurgitation is seen.\nModerate to severe [3+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Severely depressed left ventricular systolic and diastolic\ndysfunction. Depressed right ventricular function. Mild to moderate mitral\nregurgitation. Moderate to severe tricuspid regurgitation. Cannot exclude left\nventricular apical thrombus.\n\nCompared with the report of the prior study (images unavailable for review) of\n, biventricular systolic function has severely decreased.\n\n\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 566176, "text": "53 yo with PMH of DM2, HTN, hyperlipidemia, afib not on coumadin \n compliance, etoh abuse who came into ED with a subacute stroke on\n . He had expressive aphasia and right hand clumsiness. He was\n started on heparin gtt. An echo was done which showed a probable\n thrombus in the left ventricle and severe cardiomyopathy with LVEF of\n 10%. It was also noted that his LFT\ns were elevated + etoh abuse\n drinks 6-8 beers qd and hard alcohol. Abd US showing edematous\n gallbladder, ascites no cholecystitis. On floor patient temp reported\n 91 po, rectally 96 cardiology felt that there was increased concern\n for decompensated cardiac failure. He was admitted to CCU for\n aggressive diuresising and closer monitoring. Liver enzymes noted to be\n trending up since admission. Team ordered PICC for frequent lab draws.\n Cardiomyopathy, Hypertrophic\n Assessment:\n Echo done showing severe global left ventricular hypokinesis\n with ef 10-15%. A probable left ventricular thrombus. HR 70-80\ns nsr\n without ectopy bp , breathing comfortably on room air\n Action:\n Started on lopressor 12.5mg , lasix gtt @ 4mg/hr.\n Response:\n Bp 129/89 urine output >80ccqhr\n Plan:\n Lasix gtt stopped & started on 40mg po\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n a/ox3, able to move all extremities & ambulate without difficulty,\n speech only slightly garbled.\n Action:\n Heparin gtt infusing @ 750u qhr , coumadin qd.\n Response:\n Ptt wnl, INR 2.5, neuro signs remain stable\n Plan:\n Monitor neuro status, INR wnl, cont on heparin and coumadin for now d/t\n poss LV thrombus.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Nsr 70s-80s.\n Action:\n On heparin 750u and coumadin\n Response:\n INR 2.5\n Plan:\n Monitor coags, rhythm.\n Alcohol abuse\n Assessment:\n Started to get anxious around 0630, restless getting oob by himself,\n remained cooperative & a/o x3.\n Action:\n Given valium 5mg po\n Response:\n Good response, slept well.\n Plan:\n Reinforce the need to call the nurse when he gets up, bed alarm on,\n call light in reach, ciwa scale po valium prn\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n STROKE/TIA\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 75 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: DM2, HTN, afib, cardiomyopathy, likely ischemic,\n chronic systolic and diastolic chf with LVEF 10-15%\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:97\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 243 mL\n 24h total out:\n 1,240 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 07:48 AM\n Potassium:\n 3.6 mEq/L\n 07:48 AM\n Chloride:\n 100 mEq/L\n 07:48 AM\n CO2:\n 24 mEq/L\n 07:48 AM\n BUN:\n 19 mg/dL\n 07:48 AM\n Creatinine:\n 1.2 mg/dL\n 07:48 AM\n Glucose:\n 211 mg/dL\n 07:48 AM\n Hematocrit:\n 45.0 %\n 07:48 AM\n Finger Stick Glucose:\n 240\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 1440\n" }, { "category": "Physician ", "chartdate": "2102-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 566052, "text": "Chief Complaint:\n 24 Hour Events:\n No events since admission to CCU\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 80 (77 - 84) bpm\n BP: 129/96(103) {99/42(57) - 138/99(108)} mmHg\n RR: 23 (17 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 93 mL\n 96 mL\n PO:\n TF:\n IVF:\n 93 mL\n 96 mL\n Blood products:\n Total out:\n 600 mL\n 280 mL\n Urine:\n 600 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -507 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:26.0/66.4/2.6\n Assessment and Plan\n 53 yo M with alcohol abuse, HTN, severe cardiomyopathy with EF 10-15%,\n DM2 and atrial fibrillation now with subacute Left superior MCA stroke\n and possible left ventricular thrombus. Transferred to CCU for volume\n overload and poor forward flow.\n .\n #. CAD: Pt has h/o CAD per records. He had a cath sometime in the past\n at which showed 90% LAD lesion but not stented.\n -obtain records from \n -start metoprolol 12.5 \n -cont ASA 81\n .\n #. Pump: Pt has severe systolic and diastolic CHF and cardiomyopathy\n with LVEF of 10. The cardiomyopathy is likely from CAD and alcohol use.\n At this point pt seems to be volume overloaded and at that point on his\n starling curve where is not able to mainten enough cardiac output.\n -start furosemide drip. watch BP while doing so. goal 500 cc to 1 L neg\n overnight.\n -put in a foley\n -start metoprolol 12.5 \n -will hold on ACEI for now as we want permissive HTN given recent\n stroke. Will further discuss with neurology when appropriate to lower\n BP further\n .\n #LV thrombus: Pt has sever global hypokinesis. He ran out of coumadin a\n few months back and has not been taking it. Likely source of embolic\n stroke.\n -continue heparin gtt and warfarin. stop hepartin iv once INR\n therapeutic.\n .\n #Elevated liver enzymes: Pt has acute elevation of AST, ALT, AP, LDH\n and Tbili. Liver US didnt show e/o cirrhosis or portal vein thrombosis.\n Denies any h/o recent ETOH binge, mushroom consumption, herbal\n supplements. No past h/o viral hepatitis. No h/o acetaminophen\n overdose. The enzyme pattern is concerning for shock liver, which might\n happen from poor forward flow.\n -cont to trend liver enzymes\n -get direct bili\n -consider liver US with doppler\n -consider liver consult\n .\n # DM2: continue insulin and monitor finger sticks. Uncontrolled with\n A1C 8.2%.\n .\n # Elevated Cr: 1.3 today from 0.8 baseline. Could be from poor\n perfusion. Doesnt seem dehydrated.\n -cont to trend. see if it improves with diuresis\n -consider renal US to r/o obstruction(highly unlikely)\n .\n # Alcohol abuse: continue CIWA scale but change to diazepam from\n lorazepam and use PO meds. No signs of withdrawal currently. Patient\n tells me his last drink was 4 days ago.\n -SW consult\n -continue thiamine and folate and MVI\n -CIWA scale\n .\n # FEN: diabetic diet\n .\n # PPX: anticoagulation as above, bowel reg, H2 blocker\n .\n # Code: full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 566153, "text": "53 yo with PMH of DM2, HTN, hyperlipidemia, afib not on coumadin \n compliance, etoh abuse who came into ED with a subacute stroke on\n . He had expressive aphasia and right hand clumsiness. He was\n started on heparin gtt. An echo was done which showed a probable\n thrombus in the left ventricle and severe cardiomyopathy with LVEF of\n 10%. It was also noted that his LFT\ns were elevated + etoh abuse\n drinks 6-8 beers qd and hard alcohol. Abd US showing edematous\n gallbladder, ascites no cholecystitis. On floor patient temp reported\n 91 po, rectally 96 cardiology felt that there was increased concern\n for decompensated cardiac failure. He was admitted to CCU for\n aggressive diuresising and closer monitoring. Liver enzymes noted to be\n trending up since admission. Team ordered PICC for frequent lab draws.\n Cardiomyopathy, Hypertrophic\n Assessment:\n Echo done showing severe global left ventricular hypokinesis\n with ef 10-15%. A probable left ventricular thrombus. HR 70-80\ns nsr\n without ectopy bp , breathing comfortably on room air\n Action:\n Started on lopressor 12.5mg , lasix gtt @ 4mg/hr.\n Response:\n Bp 129/89 urine output >80ccqhr\n Plan:\n Lasix gtt stopped & started on 40mg po\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n a/ox3, able to move all extremities & ambulate without difficulty,\n speech only slightly garbled.\n Action:\n Heparin gtt infusing @ 750u qhr , coumadin qd.\n Response:\n Ptt wnl, INR 2.5, neuro signs remain stable\n Plan:\n Monitor neuro status, INR wnl, cont on heparin and coumadin for now d/t\n poss LV thrombus.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Nsr 70s-80s.\n Action:\n On heparin 750u and coumadin\n Response:\n INR 2.5\n Plan:\n Monitor coags, rhythm.\n Alcohol abuse\n Assessment:\n Started to get anxious around 0630, restless getting oob by himself,\n remained cooperative & a/o x3.\n Action:\n Given valium 5mg po\n Response:\n Good response, slept well.\n Plan:\n Reinforce the need to call the nurse when he gets up, bed alarm on,\n call light in reach, ciwa scale po valium prn\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n STROKE/TIA\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 75 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: DM2, HTN, afib, cardiomyopathy, likely ischemic,\n chronic systolic and diastolic chf with LVEF 10-15%\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:97\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 243 mL\n 24h total out:\n 1,240 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 07:48 AM\n Potassium:\n 3.6 mEq/L\n 07:48 AM\n Chloride:\n 100 mEq/L\n 07:48 AM\n CO2:\n 24 mEq/L\n 07:48 AM\n BUN:\n 19 mg/dL\n 07:48 AM\n Creatinine:\n 1.2 mg/dL\n 07:48 AM\n Glucose:\n 211 mg/dL\n 07:48 AM\n Hematocrit:\n 45.0 %\n 07:48 AM\n Finger Stick Glucose:\n 240\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2102-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 566135, "text": "Chief Complaint:\n 24 Hour Events:\n Patient refused blood draws this am.\n Feels better, breathing better. No abdominal pain, diarrhea.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 80 (77 - 84) bpm\n BP: 129/96(103) {99/42(57) - 138/99(108)} mmHg\n RR: 23 (17 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 93 mL\n 96 mL\n PO:\n TF:\n IVF:\n 93 mL\n 96 mL\n Blood products:\n Total out:\n 600 mL\n 280 mL\n Urine:\n 600 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -507 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n GEN: Sitting up in chair in nad\n HEENT: MMM. No scleral icterus\n NECK: JVP to earlobe when sitting at 90 degrees\n Lungs: CTAB, Bibasilar rales\n HEART: RRR\n ABD: Distended. No TTP\n EXTREM: 2+ pitting edema to knees bilaterally\n NEURO: Word finding difficulty.\n Labs / Radiology\n 145\n 45\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:25.8/61.3/2.5\n Assessment and Plan\n 53 yo M with alcohol abuse, HTN, severe cardiomyopathy with EF 10-15%,\n DM2 and atrial fibrillation now with subacute Left superior MCA stroke\n and possible left ventricular thrombus. Transferred to CCU for volume\n overload and poor forward flow.\n .\n #Elevated liver enzymes: Pt has acute elevation of AST, ALT, AP, LDH\n and Tbili. Liver US didnt show e/o cirrhosis or portal vein thrombosis.\n Denies any h/o recent ETOH binge, mushroom consumption, herbal\n supplements. No past h/o viral hepatitis. No h/o acetaminophen\n overdose. Although could have alcoholic hepatitis (given AST>ALT) the\n enzyme pattern is also concerning for shock liver, which might happen\n from poor forward flow from his severe CHF. In this setting, however,\n it seems inconsistent that his kidneys are not also receiving poor flow\n and thus having dysfunction\n instead they are functioning\n appropriately.\n -cont to trend liver enzymes if patient will allow blood draws.\n -get direct bili and iron studies\n -Consult liver team\n -f/u hepatitis serologies\n -hold statin\n -monitor for encephalopathy\n #. Pump: Pt has severe systolic and diastolic CHF and cardiomyopathy\n with LVEF of 10. The cardiomyopathy is likely from CAD and alcohol use.\n At this point pt seems to be volume overloaded and at that point on his\n starling curve where is not able to mainten enough cardiac output.\n -Putting out well to lasix gtt at 4/hr, will change to oral lasix 40mg\n QD\n -Will start captopril 6.25mg TID today\n - will change metoprolol to carvedilol\n #LV thrombus: Unclear if actually has thrombus as TTE report just says\n cannot rule out presence of thrombus. In any case, pt has severe global\n hypokinesis. He ran out of coumadin a few months back and has not been\n taking it. Likely source of embolic stroke.\n -continue heparin gtt and warfarin. stop hepartin iv if INR therapeutic\n today especially in setting of ALF.\n -Follow up INR frequently and d/c coumadin if becomes coagulopathic.\n # CVA: MRI/MRA shows no acute hemorrhage or infarct although wet read\n had suggestion of one.\n -Will follow up neuro recs re:whether should treat as had CVA or TIA\n -Will continue hep gtt and coumadin for ppx\n -Will also d/w neuro the utility of permissive HTN if does not have\n evidence of stroke on imaging as would be better to allow lower BPs to\n have more diuresis without having to start pressor.\n # Elevated Cr: 1.3 today from 0.8 baseline. Could be from poor\n perfusion. Doesnt seem dehydrated.\n -cont to trend. see if it improves with diuresis\n -consider renal US to r/o obstruction(highly unlikely)\n # Alcohol abuse: continue CIWA scale but change to diazepam from\n lorazepam and use PO meds. No signs of withdrawal currently. Patient\n tells me his last drink was 4 days ago.\n -SW consult\n -continue thiamine and folate and MVI\n -CIWA scale\n #. CAD: Pt has h/o CAD per records. He had a cath sometime in the past\n at which showed 90% LAD lesion but not stented.\n -obtain records from \n -start metoprolol 12.5 \n -cont ASA 81\n -holding statin given transaminitis.\n # DM2: continue insulin and monitor finger sticks. Uncontrolled with\n A1C 8.2%.\n # FEN: diabetic diet\n # PPX: anticoagulation as above, bowel reg, H2 blocker\n # Code: full\n ICU Care\n Nutrition: HH/DM2\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Patient very hard stick and refusing further blood draws. IV tried PICC\n at bedside yesterday without success. Consider IR for PICC placement\n today.\n Prophylaxis:\n DVT: Hep gtt and coumadin\n Stress ulcer: H2 blocker\n Communication: With patient\n Code status: Full code\n Disposition: call out to 3\n" }, { "category": "Physician ", "chartdate": "2102-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 566128, "text": "Chief Complaint:\n 24 Hour Events:\n Patient refused blood draws this am.\n Feels better, breathing better. No abdominal pain, diarrhea.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 80 (77 - 84) bpm\n BP: 129/96(103) {99/42(57) - 138/99(108)} mmHg\n RR: 23 (17 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 93 mL\n 96 mL\n PO:\n TF:\n IVF:\n 93 mL\n 96 mL\n Blood products:\n Total out:\n 600 mL\n 280 mL\n Urine:\n 600 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -507 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n GEN: Sitting up in chair in nad\n HEENT: MMM. No scleral icterus\n NECK: JVP to earlobe when sitting at 90 degrees\n Lungs: CTAB\n HEART: RRR\n ABD: Distended. No TTP\n EXTREM: 2+ pitting edema to knees bilaterally\n NEURO: Word finding difficulty.\n Labs / Radiology\n 145\n 45\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:25.8/61.3/2.5\n Assessment and Plan\n 53 yo M with alcohol abuse, HTN, severe cardiomyopathy with EF 10-15%,\n DM2 and atrial fibrillation now with subacute Left superior MCA stroke\n and possible left ventricular thrombus. Transferred to CCU for volume\n overload and poor forward flow.\n .\n #Elevated liver enzymes: Pt has acute elevation of AST, ALT, AP, LDH\n and Tbili. Liver US didnt show e/o cirrhosis or portal vein thrombosis.\n Denies any h/o recent ETOH binge, mushroom consumption, herbal\n supplements. No past h/o viral hepatitis. No h/o acetaminophen\n overdose. Although could have alcoholic hepatitis (given AST>ALT) the\n enzyme pattern is also concerning for shock liver, which might happen\n from poor forward flow from his severe CHF. In this setting, however,\n it seems inconsistent that his kidneys are not also receiving poor flow\n and thus having dysfunction\n instead they are functioning\n appropriately.\n -cont to trend liver enzymes if patient will allow blood draws.\n -get direct bili\n -consider liver US with doppler\n -consider liver consult\n -f/u hepatitis serologies\n -hold statin\n -monitor for encephalopathy\n #. Pump: Pt has severe systolic and diastolic CHF and cardiomyopathy\n with LVEF of 10. The cardiomyopathy is likely from CAD and alcohol use.\n At this point pt seems to be volume overloaded and at that point on his\n starling curve where is not able to mainten enough cardiac output.\n -Putting out well to lasix gtt at 4/hr\n -Continue metoprolol 12.5 \n -will hold on ACEI for now as neuro had suggested permissive HTN given\n recent stroke. Will further discuss with neurology when appropriate to\n lower BP further given MRA/MRI was negative for acute stroke on final\n read\n #LV thrombus: Unclear if actually has thrombus as TTE report just says\n cannot rule out presence of thrombus. In any case, pt has severe global\n hypokinesis. He ran out of coumadin a few months back and has not been\n taking it. Likely source of embolic stroke.\n - Will get TEE today to evaluate presence of thrombus\n -continue heparin gtt and warfarin. stop hepartin iv if INR therapeutic\n today especially in setting of ALF.\n -Follow up INR frequently and d/c coumadin if becomes coagulopathic.\n # CVA: MRI/MRA shows no acute hemorrhage or infarct although wet read\n had suggestion of one.\n -Will follow up neuro recs re:whether should treat as had CVA or TIA\n -Will continue hep gtt and coumadin for ppx\n -Will also d/w neuro the utility of permissive HTN if does not have\n evidence of stroke on imaging as would be better to allow lower BPs to\n have more diuresis without having to start pressor.\n # Elevated Cr: 1.3 today from 0.8 baseline. Could be from poor\n perfusion. Doesnt seem dehydrated.\n -cont to trend. see if it improves with diuresis\n -consider renal US to r/o obstruction(highly unlikely)\n # Alcohol abuse: continue CIWA scale but change to diazepam from\n lorazepam and use PO meds. No signs of withdrawal currently. Patient\n tells me his last drink was 4 days ago.\n -SW consult\n -continue thiamine and folate and MVI\n -CIWA scale\n #. CAD: Pt has h/o CAD per records. He had a cath sometime in the past\n at which showed 90% LAD lesion but not stented.\n -obtain records from \n -start metoprolol 12.5 \n -cont ASA 81\n -holding statin given transaminitis.\n # DM2: continue insulin and monitor finger sticks. Uncontrolled with\n A1C 8.2%.\n # FEN: diabetic diet\n # PPX: anticoagulation as above, bowel reg, H2 blocker\n # Code: full\n ICU Care\n Nutrition: HH/DM2\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Patient very hard stick and refusing further blood draws. IV tried PICC\n at bedside yesterday without success. Consider IR for PICC placement\n today.\n Prophylaxis:\n DVT: Hep gtt and coumadin\n Stress ulcer: H2 blocker\n Communication: With patient\n Code status: Full code\n Disposition: pending diuresis\n" }, { "category": "ECG", "chartdate": "2102-03-17 00:00:00.000", "description": "Report", "row_id": 187589, "text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. There are\nST-T wave changes most consistent with underlying left ventricular hypertrophy,\nalthough ischemia or myocardial infarction cannot be excluded. Compared to the\nprevious tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2102-03-14 00:00:00.000", "description": "Report", "row_id": 187590, "text": "Sinus rhythm. Consider biatrial abnormality, although this is non-diagnostic.\nLeft axis deviation may be due to left anterior fascicular block. Low limb\nlead QRS voltage. Prominent precordial lead QRS voltage raises consideration\nof left ventricular hypertrophy. Delayed R wave progression may be due to left\nventricular hypertrophy or possible prior septal myocardial infarction.\nST-T wave abnormalities may be due to left ventricular hypertrophy but\ncannot exclude ischemia. Clinical correlation is suggested. Since the\nprevious tracing of sinus tachycardia is absent, atrial abnormality is\nsuggested, axis is more leftward, low limb lead QRS voltage is present,\nprecordial lead QRS voltage is more prominent and further T wave changes are\npresent.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-15 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1070922, "text": " 3:49 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: to look for ascites, and liver nodules\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ascites, hepatosplenomegaly\n REASON FOR THIS EXAMINATION:\n to look for ascites, and liver nodules\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with ascites and hepatosplenomegaly. Assess for\n ascites and liver nodules.\n\n COMPARISON STUDIES: None.\n\n ABDOMEN ULTRASOUND: No focal or textural liver abnormality is identified.\n There is some enlargement of the left hepatic lobe. There is no intra- or\n extra-hepatic biliary dilatation. The CBD measures 6 mm. The gallbladder is\n not distended. The gallbladder wall is markedly edematous, measuring up to 6\n mm in thickness. Several limited structures in the gallbladder lumen could\n represent folds. No cholelithiasis is seen. There is no fluid immediately\n surrounding the gallbladder. The main portal vein is patent with hepatopetal\n flow. The spleen is normal in size measuring 8.1 cm in greatest diameter.\n Images of the pancreas are limited due to overlying bowel gas. The right\n kidney measures 10.4 cm in length. The left kidney measures 10.6 cm in\n length. There is no hydronephrosis or nephrolithiasis in either kidney. There\n is a small amount of ascites.\n\n IMPRESSION:\n\n 1. No gross focal or textural liver abnormalities. Possible hypertrophy of\n the left lobe.\n\n 2. Edematous gallbladder in the setting of ascites. No evidence of\n cholecystitis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-17 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 1071324, "text": " 3:35 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Please complete liver US with DOPPLER\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with elevated LFTS\n REASON FOR THIS EXAMINATION:\n Please complete liver US with DOPPLER\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CLxc FRI 7:03 PM\n PFI: Patent hepatic vasculature, including the portal venous system, hepatic\n vein and common hepatic artery. IVC, superior mesenteric vein and splenic\n vein are also patent.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old man with elevated LFTs, please perform liver ultrasound\n with Doppler.\n\n TECHNIQUE: A real-time -scale ultrasound with color and spectral Doppler\n was performed. Comparison is made to a prior abdominal ultrasound performed\n .\n\n FINDINGS: Again seen is enlargement of the left lobe of the liver. No focal\n liver lesions are identified. No evidence of intra- or extra-hepatic bile\n duct dilation. Gallbladder is partially distended without gallstones.\n\n Main, right and left portal veins are patent with hepatopetal flow. There is\n exaggerated phasicity of the portal venous spectral Doppler waveforms. This\n finding is of uncertain clinical significance but can be seen in the setting\n of right heart failure or tricuspid regurgitation.\n\n Middle, right and left hepatic veins are patent with appropriate waveforms.\n Common hepatic artery is patent with appropriate direction of flow. Superior\n mesenteric and splenic veins are patent. IVC is patent.\n\n IMPRESSION: Patent hepatic vasculature including the portal and hepatic\n veins and hepatic arteries.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-17 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 1071325, "text": ", I. 3:35 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Please complete liver US with DOPPLER\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with elevated LFTS\n REASON FOR THIS EXAMINATION:\n Please complete liver US with DOPPLER\n ______________________________________________________________________________\n PFI REPORT\n PFI: Patent hepatic vasculature, including the portal venous system, hepatic\n vein and common hepatic artery. IVC, superior mesenteric vein and splenic\n vein are also patent.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-17 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1071301, "text": " 2:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Picc placement\n Admitting Diagnosis: STROKE/TIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with poor access and difficult blood draws. IV was unable to\n place PICC at bedside yesterday\n REASON FOR THIS EXAMINATION:\n Picc placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc FRI 4:39 PM\n Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line\n placement via the right basilic venous approach. Final internal length is 45\n cm, with the tip positioned in SVC. The line is ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: Difficult blood draws, patient with poor access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. and Dr the attending radiologist who\n was present and supervising.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a single lumen PICC line measuring 45 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided right PICC\n line placement via the right basilic approach. Final internal length is 45\n cm, with the tip positioned in SVC. The line is ready to use.\n\n\n (Over)\n\n 2:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Picc placement\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2102-03-17 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1071302, "text": ", I. 2:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Picc placement\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with poor access and difficult blood draws. IV was unable to\n place PICC at bedside yesterday\n REASON FOR THIS EXAMINATION:\n Picc placement\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line\n placement via the right basilic venous approach. Final internal length is 45\n cm, with the tip positioned in SVC. The line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-14 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1070774, "text": " 7:49 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: eval for bleed, infarct\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with speech changes x 3+ hours, R pronator\n REASON FOR THIS EXAMINATION:\n eval for bleed, infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa TUE 9:01 PM\n Left fronto-temporal hypodensity with increased MTT, decreased blood flow. No\n cut off seen on vessels on CTA but recons pending.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Speech changes lasting three hours as well as right pronator drift.\n\n COMPARISON: No prior studies are available for comparison.\n\n TECHNIQUE: Contiguous axial CT images were acquired through the brain in the\n absence of contrast. Following the administration of 120 cc of intravenous\n Optiray contrast, contiguous axial CT images were acquired from the level of\n the aortic arch through the brain. Coronal and sagittal reformatted images\n were also reviewed as were multiple vascular reconstruction images. Blood\n flow, volume and mean transit time images were also reviewed.\n\n WET READ: The following wet read was entered into the PACS: \"No acute\n intracranial pathology; left maxillary sinus disease.\"\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or\n vascular territory infarction. The ventricles and sulci are normal in size\n and configuration. Visualized osseous structures show no fractures. Paranasal\n sinuses are notable for bilateral, maxillary mucosal thickening. The\n visualized portions of the lung apices are unremarkable, as are the soft\n tissues of the neck.\n\n Post-contrast images show the carotid and vertebral arteries, as well as their\n main branches, bilaterally to be patent with stenoses or aneurysm. Luminal\n measurements at the ICA's show the right ICA measuring 5.7 mm proximally and\n 4.3 mm distally. On the left, the ICA measures 6.1 mm proximally and 4.0 mm\n distally. There is slight narrowing in the caliber of the distal basilar\n artery, which remains patent and may be a hypoplastic segment.\n\n Incidentally, scout images show cortical irregularity at the midshaft of the\n left humerus, suggesting remote fracture as well as an enlarged cardiac\n silhouette.\n\n IMPRESSION:\n No acute intracranial process with no abnormal enhancement, infarction or\n hemorrhage.\n\n (Over)\n\n 7:49 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n CT BRAIN PERFUSION\n Reason: eval for bleed, infarct\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2102-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1070784, "text": " 9:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with stroke\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Stroke.\n\n COMPARISON: None.\n\n UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is enlarged with a left\n ventricular predominance. The pulmonary vascularity is within normal limits.\n Mediastinal and hilar contours are unremarkable. The lungs are clear. No\n pleural effusion or pneumothorax. Gaseous structure within normal limits.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 566104, "text": "53 yo with PMH of DM2, HTN, hyperlipidemia, afib not on coumadin \n compliance, etoh abuse who came into ED with a subacute stroke on\n . He had expressive aphasia and right hand clumsiness. He was\n started on heparin gtt. An echo was done which showed a probable\n thrombus in the left ventricle and severe cardiomyopathy with LVEF of\n 10%. It was also noted that his LFT\ns were elevated + etoh abuse\n drinks 6-8 beers qd and hard alcohol. Abd US showing edematous\n gallbladder, ascites no cholecystitis. On floor patient temp reported\n 91 po, rectally 96 cardiology felt that there was increased concern\n for decompensated cardiac failure. He was admitted to CCU for\n aggressive diuresising and closer monitoring.\n Cardiomyopathy, Hypertrophic\n Assessment:\n Echo done showing severe global left ventricular hypokinesis\n with ef 10-15%. A probable left ventricular thrombus. HR 70-80\ns nsr\n without ectopy bp , breathing comfortably on room air\n Action:\n Started on lopressor 12.5mg , lasix gtt started 2-4mg/hr\n Response:\n Bp 129/89 urine output >80ccqhr\n Plan:\n Lasix titrated to keep urine output > 80cc qhr,\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n a/ox3, able to ambulate without difficulty, speech difficult to\n understand at times patient stated that he felt it was back to baseline\n he is followed by rehab services who felt that he was unaware of his\n higher level language deficits.\n Action:\n Heparin gtt 750u qhr , receiving coumadin po\n Response:\n Ptt wnl, INR 2.6, neuro signs stable\n Plan:\n Monitor neuro status, INR wnl may be able to d/c heparin and continue\n the coumadin\n Atrial fibrillation (Afib)\n Assessment:\n Nsr INR 2.6\n Action:\n On heparin 750u and coumadin\n Response:\n Plan:\n monitor\n Alcohol abuse\n Assessment:\n Started to get anxious around 0630, restless getting oob by himself,\n a/o x3, ambulates\n Action:\n Given valium 5mg po\n Response:\n Less anxious\n Plan:\n Reinforce the need to call the nurse when he gets up, bed alarm on,\n call light in reach, ciwa scale po valium prn\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 566032, "text": "53 yo with PMH of DM2, HTN, afib not on coumadin, etoh abuse who came\n into ED with a subacute stroke on . He had expressive aphasia\n and right hand clumsiness. He was started on heparin gtt. An echo was\n done which showed a probable thrombus in the left ventricle and severe\n cardiomyopathy with LVEF of 10%. It was also noted that his LFT\ns were\n elevated + etoh abuse drinks 6-8 beers qd and hard alcohol\n Cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 566033, "text": "53 yo with PMH of DM2, HTN, afib not on coumadin, etoh abuse who came\n into ED with a subacute stroke on . He had expressive aphasia\n and right hand clumsiness. He was started on heparin gtt. An echo was\n done which showed a probable thrombus in the left ventricle and severe\n cardiomyopathy with LVEF of 10%. It was also noted that his LFT\ns were\n elevated + etoh abuse drinks 6-8 beers qd and hard alcohol. Abd US\n showing edematous gallbladder, ascites no cholecystitis. On floor\n patient temp reported 91 po, rectally 96 cardiology felt that there was\n increased concern\n Cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2102-03-16 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 566023, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: (Other: vol overload)\n History of present illness: For full details please refer to prior H&P.\n Briefly, 53yo M with h/o CAD, AF not taking his coumadin, and CHF\n admitted with stroke. Patient was at home when he developed\n speech difficulties, right sided hand weakness, and right-sided visual\n disturbances. He told the ED physicians that he had stopped taking his\n coumadin when his prescription ran out about 6 months ago. His PCP, .\n also confirmed this. He was admitted to the neurology service\n for \"code stroke\", however he was past the time limit for TPA. He was\n started on heparin, asa, and CIWA scale overnight. MRI/A was performed\n and showed no focal lesions. TTE showed LV thrombus and EF 10%.\n He was already on IV heparin for the stroke which was continued after\n finding the LV thrombus. He was transferred to medicine for further\n care.\n .\n On the day of tranfer to the CCU, he was noted to have a rectal temp of\n 96. His BP at that time was 100/60. He also had acute rise in liver\n enzymes and serum creatinine. This was thought to be from poor forward\n flow. He was xferred to CCU for aggressive diuresis.\n Past medical history: -Atrial fibrillation not on coumadin because he\n ran out of medication about 6months ago and did not refill it.\n -Cardiomyopathy- likely ischemic but maybe also be alcohol related\n chronic systolic and diastolic CHF with LVEF 10-15%\n .\n .\n Percutaneous coronary intervention:\n 90% LAD lesion but not stented, at .\n .\n Other Past History:\n DM2\n HTN\n Hyperlipidemia\n CAD Risk Factors\n CAD Risk Factors Present\n Diabetes mellitus, Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Family Hx of CAD\n Allergies:\n Penicillins\n Unknown;\n Current medications: Unclear but the neurology team called his\n pharmacies and found the following information:\n Sq, he filled a script on for\n -Toprol Xl 100 mg daily\n -Omeprazole 20 mg daily\n -Androgel 1% pump\n The Target Pharmacy mentioned that he filled the following\n -Lasix 40 mg in \n -Metoprolol ER 200 mg \n -Coumadin 5 mg \n -Humalog 7 U with meals and Lantus 20 u at night in \n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n DOE, TIA / CVA\n Social History\n Social history details: 6-8 beers a night plus hard liquor. Pt lives in\n with his first wife and their 3 children ages\n 23,22,21. Pt also has a 7 yo son who lives with pt's current\n wife who does not live with pt. He is retired form the on\n disability\n Physical Exam\n Vital signs: per R.N.\n Height: 66 Inch, 168 cm\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: JVP, upto R ear)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: WNL)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No), (Other\n abnormalities: distended)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Edema: Right: 1+, Left: 1+)\n Tests\n Echocardiogram: (Date: ), The left atrium is normal in size. The\n right atrium is moderately dilated. The estimated right atrial pressure\n is 10-20mmHg. Left ventricular wall thicknesses are normal. The left\n ventricular cavity is moderately dilated. There is severe global left\n ventricular hypokinesis (LVEF = %). A left ventricular\n mass/thrombus cannot be excluded. Transmitral Doppler and tissue\n velocity imaging are consistent with Grade III/IV (severe) LV diastolic\n dysfunction. The right ventricular cavity is mildly dilated with\n depressed free wall contractility. There is abnormal diastolic septal\n motion/position consistent with right ventricular volume overload. The\n aortic valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n structurally normal. There is no mitral valve prolapse. Mild to\n moderate (+) mitral regurgitation is seen. Moderate to severe [3+]\n tricuspid regurgitation is seen. There is mild pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n .\n IMPRESSION: Severely depressed left ventricular systolic and diastolic\n dysfunction. Depressed right ventricular function. Mild to moderate\n mitral regurgitation. Moderate to severe tricuspid regurgitation.\n Cannot exclude left ventricular apical thrombus.\n Assessment and Plan\n 53 yo M with alcohol abuse, HTN, severe cardiomyopathy with EF 10-15%,\n DM2 and atrial fibrillation now with subacute Left superior MCA stroke\n and possible left ventricular thrombus. Transferred to CCU for volume\n overload and poor forward flow.\n .\n #. CAD: Pt has h/o CAD per records. He had a cath sometime in the past\n at which showed 90% LAD lesion but not stented.\n -obtain records from \n -start metoprolol 12.5 \n -cont ASA 81\n .\n #. Pump: Pt has severe systolic and diastolic CHF and cardiomyopathy\n with LVEF of 10. The cardiomyopathy is likely from CAD and alcohol use.\n At this point pt seems to be volume overloaded and at that point on his\n starling curve where is not able to mainten enough cardiac output.\n -start furosemide drip. watch BP while doing so. goal 500 cc to 1 L neg\n overnight.\n -put in a foley\n -start metoprolol 12.5 \n -will hold on ACEI for now as we want permissive HTN given recent\n stroke. Will further discuss with neurology when appropriate to lower\n BP further\n .\n #LV thrombus: Pt has sever global hypokinesis. He ran out of coumadin a\n few months back and has not been taking it. Likely source of embolic\n stroke.\n -continue heparin gtt and warfarin. stop hepartin iv once INR\n therapeutic.\n .\n #Elevated liver enzymes: Pt has acute elevation of AST, ALT, AP, LDH\n and Tbili. Liver US didnt show e/o cirrhosis or portal vein thrombosis.\n Denies any h/o recent ETOH binge, mushroom consumption, herbal\n supplements. No past h/o viral hepatitis. No h/o acetaminophen\n overdose. The enzyme pattern is concerning for shock liver, which might\n happen from poor forward flow.\n -cont to trend liver enzymes\n -get direct bili\n -consider liver US with doppler\n -consider liver consult\n .\n # DM2: continue insulin and monitor finger sticks. Uncontrolled with\n A1C 8.2%.\n .\n # Elevated Cr: 1.3 today from 0.8 baseline. Could be from poor\n perfusion. Doesnt seem dehydrated.\n -cont to trend. see if it improves with diuresis\n -consider renal US to r/o obstruction(highly unlikely)\n .\n # Alcohol abuse: continue CIWA scale but change to diazepam from\n lorazepam and use PO meds. No signs of withdrawal currently. Patient\n tells me his last drink was 4 days ago.\n -SW consult\n -continue thiamine and folate and MVI\n -CIWA scale\n .\n # FEN: diabetic diet\n .\n # PPX: anticoagulation as above, bowel reg, H2 blocker\n .\n # Code: full\n .\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 566034, "text": "53 yo with PMH of DM2, HTN, hyperlipidemia, afib not on coumadin, etoh\n abuse who came into ED with a subacute stroke on . He had\n expressive aphasia and right hand clumsiness. He was started on heparin\n gtt. An echo was done which showed a probable thrombus in the left\n ventricle and severe cardiomyopathy with LVEF of 10%. It was also\n noted that his LFT\ns were elevated + etoh abuse drinks 6-8 beers qd and\n hard alcohol. Abd US showing edematous gallbladder, ascites no\n cholecystitis. On floor patient temp reported 91 po, rectally 96\n cardiology felt that there was increased concern for decompensated\n cardiac failure. He was admitted to CCU for aggressive diuresising and\n closer monitoring.\n Cardiomyopathy, Hypertrophic\n Assessment:\n Echo done showing severe global left ventricular hypokinesis\n with ef 10-15%. A probable left ventricular thrombus. HR 70-80\ns nsr\n without ectopy bp , breathing comfortably on room air\n Action:\n Started on lopressor 12.5mg , lasix gtt started 2-4mg/hr\n Response:\n Bp 129/89 urine output >80ccqhr\n Plan:\n Lasix titrated to keep urine output > 80cc qhr,\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 566030, "text": "53 yo with PMH of DM2, HTN, afib not on coumadin, etoh abuse who came\n into ED with a subacute stroke on . He had expressive aphasia\n and right hand clumsiness. He was started on heparin gtt. An echo was\n done which showed a probable thrombus in the left ventricle and severe\n cardiomyopathy with LVEF of 10%. It was also noted that his LFT\ns were\n elevated\n Cardiomyopathy, Hypertrophic\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2102-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 566115, "text": "Chief Complaint:\n 24 Hour Events:\n Patient refused blood draws this am.\n Feels better, breathing better. No abdominal pain, diarrhea.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 80 (77 - 84) bpm\n BP: 129/96(103) {99/42(57) - 138/99(108)} mmHg\n RR: 23 (17 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 93 mL\n 96 mL\n PO:\n TF:\n IVF:\n 93 mL\n 96 mL\n Blood products:\n Total out:\n 600 mL\n 280 mL\n Urine:\n 600 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -507 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n GEN: Sitting up in chair in nad\n HEENT: MMM. No scleral icterus\n NECK: JVP to earlobe when sitting at 90 degrees\n Lungs: CTAB\n HEART: RRR\n ABD: Distended. No TTP\n EXTREM: 2+ pitting edema to knees bilaterally\n NEURO: Word finding difficulty.\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:26.0/66.4/2.6\n Assessment and Plan\n 53 yo M with alcohol abuse, HTN, severe cardiomyopathy with EF 10-15%,\n DM2 and atrial fibrillation now with subacute Left superior MCA stroke\n and possible left ventricular thrombus. Transferred to CCU for volume\n overload and poor forward flow.\n .\n #Elevated liver enzymes: Pt has acute elevation of AST, ALT, AP, LDH\n and Tbili. Liver US didnt show e/o cirrhosis or portal vein thrombosis.\n Denies any h/o recent ETOH binge, mushroom consumption, herbal\n supplements. No past h/o viral hepatitis. No h/o acetaminophen\n overdose. Although could have alcoholic hepatitis (given AST>ALT) the\n enzyme pattern is also concerning for shock liver, which might happen\n from poor forward flow from his severe CHF. In this setting, however,\n it seems inconsistent that his kidneys are not also receiving poor flow\n and thus having dysfunction\n instead they are functioning\n appropriately.\n -cont to trend liver enzymes if patient will allow blood draws.\n -get direct bili\n -consider liver US with doppler\n -consider liver consult\n -f/u hepatitis serologies\n -hold statin\n -monitor for encephalopathy\n #. Pump: Pt has severe systolic and diastolic CHF and cardiomyopathy\n with LVEF of 10. The cardiomyopathy is likely from CAD and alcohol use.\n At this point pt seems to be volume overloaded and at that point on his\n starling curve where is not able to mainten enough cardiac output.\n -Putting out well to lasix gtt at 4/hr\n -Continue metoprolol 12.5 \n -will hold on ACEI for now as neuro had suggested permissive HTN given\n recent stroke. Will further discuss with neurology when appropriate to\n lower BP further given MRA/MRI was negative for acute stroke on final\n read\n #LV thrombus: Unclear if actually has thrombus as TTE report just says\n cannot rule out presence of thrombus. In any case, pt has severe global\n hypokinesis. He ran out of coumadin a few months back and has not been\n taking it. Likely source of embolic stroke.\n -continue heparin gtt and warfarin. stop hepartin iv if INR therapeutic\n today especially in setting of ALF.\n -Follow up INR frequently and d/c coumadin if becomes coagulopathic.\n # CVA: MRI/MRA shows no acute hemorrhage or infarct although wet read\n had suggestion of one.\n -Will follow up neuro recs re:whether should treat as had CVA or TIA\n -Will continue hep gtt and coumadin for ppx\n -Will also d/w neuro the utility of permissive HTN if does not have\n evidence of stroke on imaging as would be better to allow lower BPs to\n have more diuresis without having to start pressor.\n # Elevated Cr: 1.3 today from 0.8 baseline. Could be from poor\n perfusion. Doesnt seem dehydrated.\n -cont to trend. see if it improves with diuresis\n -consider renal US to r/o obstruction(highly unlikely)\n # Alcohol abuse: continue CIWA scale but change to diazepam from\n lorazepam and use PO meds. No signs of withdrawal currently. Patient\n tells me his last drink was 4 days ago.\n -SW consult\n -continue thiamine and folate and MVI\n -CIWA scale\n #. CAD: Pt has h/o CAD per records. He had a cath sometime in the past\n at which showed 90% LAD lesion but not stented.\n -obtain records from \n -start metoprolol 12.5 \n -cont ASA 81\n -holding statin given transaminitis.\n # DM2: continue insulin and monitor finger sticks. Uncontrolled with\n A1C 8.2%.\n # FEN: diabetic diet\n # PPX: anticoagulation as above, bowel reg, H2 blocker\n # Code: full\n ICU Care\n Nutrition: HH/DM2\n Glycemic Control:\n Lines:\n 18 Gauge - 07:00 PM\n Patient very hard stick and refusing further blood draws. IV tried PICC\n at bedside yesterday without success. Consider IR for PICC placement\n today.\n Prophylaxis:\n DVT: Hep gtt and coumadin\n Stress ulcer: H2 blocker\n Communication: With patient\n Code status: Full code\n Disposition: pending diuresis\n" }, { "category": "Nursing", "chartdate": "2102-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 566039, "text": "53 yo with PMH of DM2, HTN, hyperlipidemia, afib not on coumadin, etoh\n abuse who came into ED with a subacute stroke on . He had\n expressive aphasia and right hand clumsiness. He was started on heparin\n gtt. An echo was done which showed a probable thrombus in the left\n ventricle and severe cardiomyopathy with LVEF of 10%. It was also\n noted that his LFT\ns were elevated + etoh abuse drinks 6-8 beers qd and\n hard alcohol. Abd US showing edematous gallbladder, ascites no\n cholecystitis. On floor patient temp reported 91 po, rectally 96\n cardiology felt that there was increased concern for decompensated\n cardiac failure. He was admitted to CCU for aggressive diuresising and\n closer monitoring.\n Cardiomyopathy, Hypertrophic\n Assessment:\n Echo done showing severe global left ventricular hypokinesis\n with ef 10-15%. A probable left ventricular thrombus. HR 70-80\ns nsr\n without ectopy bp , breathing comfortably on room air\n Action:\n Started on lopressor 12.5mg , lasix gtt started 2-4mg/hr\n Response:\n Bp 129/89 urine output >80ccqhr\n Plan:\n Lasix titrated to keep urine output > 80cc qhr,\n CVA (Stroke, Cerebral infarction), Ischemic\n Assessment:\n a/ox3, able to ambulate without difficulty, speech difficult to\n understand at times patient stated that he felt it was back to baseline\n he is followed by rehab services who felt that he was unaware of his\n higher level language deficits.\n Action:\n Heparin gtt 750u qhr , receiving coumadin po\n Response:\n Ptt wnl, INR 2.6, neuro signs stable\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

[ { "category": "Nursing/other", "chartdate": "2175-02-07 00:00:00.000", "description": "Report", "row_id": 1853106, "text": "Admission Note\nPt is a 36 hour old full term male newborn. Pt was born to a 31 year old G1P0 mother with that were; Hep B negative, RPR NR, A positive, AB negative, Rubella Immune, GBS positive. Mother had a low grade temp < 100.3F and did recieve Intapartum antibiotics. There was a prenatal history of bilateral chorionic cysts which resolved prior to delivery. Pt was born vaginal, by vaccum assist, and had good apgars of . There was no meconium noted at delivery. The infant initially went to the newborn nursery and did well with the exception of some feeding difficulty. The D-sticks were normal and were checked due to size at birth (4.4kg). This morning (about 9:30a) pt was noted to have jerky right sided movements that lasted about one minute on the first episode. The pedi was notified and came in to exam the infant. The infant had two more episodes lasting 3-5 minutes. Upon seeing this the Pedi transfered the patient to the NICU for further work up (about 11:30a). There is no signifcant family history of seizures on either side.\nUpn admission to the NICU the pt had another 4.5 minute right sided focal tonic clonic seizure. D-stick at that time was in the 70's. Pt did desat to mid 70's and required blow by O2 for about 2-3 minutes. On exam:\nGEN: Well developed Male infant appearing post ictal after seizure\nHEENT: AFSF, nares patent, MMM, palate intact, PERRL\nNeck: supple\nChest: Erythyma around right nipple, CTA B, good air entry\nCV: RRR, no murmur noted. pulses 2+ femoral\nABD: Soft, NT +BS no masses\nGU: Recently Circ male, testes down B\nEXTS: CR< 3sec\nNeuro: exagerated moro but sym., + suck, + grasp, slight increased tone throughout, brisk reflexes L>R, no clonus noted\n\nA: 36hour old male newborn with new onset seizures. Plan to continue work up, pt stable currently in room air.\nP:\n1) F/E/N- Will start IV for access and have D10W with lytes running at 40cc/kg/D. If patient stable would continue feeding. Will send baseline lytes, CA,MG,PO4,BUN, Creat, and gas now.\n2) RESP: WIll watch sats in room air, will give blow by if needed\n3) CV: Stable\n4) ID: We have sent CBC with Diff, Blood culture, and LP for culture and HSV PCR. We will start Ampicillin, Gent, and acyclovir.\n5) Neuro: A neuro consult was obtained. After the babies 5th seizure the patient was loaded with 20mg/kg of Phenobarbital. A CT scan is pending and EEG will be done this afternoon. Will continue work up based on results.\n6) Social: I have talked to the family several times today updating them about his condition, our current plans and getting consent for LP. Family is aware of plan and are appropriately concerned. Will continue to keep family updated and involved.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-07 00:00:00.000", "description": "Report", "row_id": 1853107, "text": "Procedure Note\nAn LP was performed on this patient after consent was obatianed as part of the work up for seizures. The patient was prepped and draped in the usual manner. A 22 gauge spinal needle was inserted between L3 and L4 on the first attempt. There was a slight blood tinge to the CSF which cleared rapidly. 4cc of xanthochromic CSF was obtained and sent to the lab for studies. The patient tolerated the procedure well and there were no complications.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-07 00:00:00.000", "description": "Report", "row_id": 1853108, "text": "Neonatology\nTerm newborn sent to NICU for evaluation and management of seizures. Hx and PE as anoted by Dr . Briefly born by vacuum assisted vaginal delivery. Did well in DR subsequently in NN until this am when had episodes of TC movements of right side. WHen observed in NICU were clearly related to seizure activity. Except for single desat in NICU these have not been associated with abnormalities of breathing. Initial metabolic screening of lytes and BS are normal. Csf exam shows no evidence of SAH or pleocytosis. Recurrence of seizure in NIUC rxed with 20 mg/kg phenobarbital. No sz since dosing.\n\nExam as noted by Dr is concordant with mine.\n\nCT scan done this afternoon. Awaiting report. EEG also pending. Other tests pending as per neuro team.\n\nA- term infant with seizures. No obvious etiology at present.\nP Admit NICU\n Clincial and non-invasive monitoring of resp status.\n NPO for now with IV hydration. COnsider feeds again later tonoc.\n Coverage with amp, gent and acyclovir pending microbiologic results and course.\n Usual attention to metabolic issues.\n Plan to start on maintenance anti-convulsant in am.\n Parents aware of status and plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-07 00:00:00.000", "description": "Report", "row_id": 1853109, "text": "SOCIAL WORK\nMet parents briefly to offer support during their son's work up for seizures. They are understandbly anxious for results from EEG. Parents aware that I will be unavailable . Please contact # should concerns arise. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-10 00:00:00.000", "description": "Report", "row_id": 1853125, "text": "Nrsg Progress Note-0700-1500\n\n\n#1/#2O/A-Rem alert and active with cares waking on own q 2-3\nhours. Lusty non high pitched cry. Moving all extremities\nequally. A-G&D needs wnl this shift. P_Cont to assess g&d\nneeds.No seizure activity noted this shift. Rem on\nphenobarb.Plans for neuro f/u for 1 week. P-Cont to assess\nneuro needs.\n#3O/A-Mom and dad both here at bedside with complete update\ngiven. Mom and dad both present with neurology visited\ntoday. Mom may want VNA for f/u. Plans for pedi appt to be\nmade for Monday . aware hep b given.\nA-Parenting needs wnl this shift. P-Cont to assess parenting\nneeds.\n#4O/A- on demand with latching on and swallowing\nnoted. Lge soft yellow stools noted x 1. Lge void with each\ndiaper change. A-Fen needs wnl this shift. P-Cont to assess\nfen needs.\n#5O/AHsv cultures remain pending with no overt sepsis signs.\nRem alert waking on own for cares. Temp stable in oc.\nA-Sepsi needs with hsv cultures pending.P-Cont to assess\nsepsis needs.\nNo apnea, bradycardia,or desats noted this shift. Continues\nto have low resting ap 90-110 with Dr. aware.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-10 00:00:00.000", "description": "Report", "row_id": 1853126, "text": "NICU Fellow Exam Note\nGEN: Crying, Awake\nHEENT: AFSF, MMM\nChest: CTA B\nCV: RRR no murmur noted\nABD: Soft, NT +BS\nExts: CR< 3 sec\nNeuro: Increased tone in lower exts.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-10 00:00:00.000", "description": "Report", "row_id": 1853127, "text": "Nursing Note\n\n\n#1O: On open warmer with stable temp. Active and alert\nwith cares, awake alot of . Responsive to voice, loves\nbeing held.\n#2O: No signs of sx activity. Phenobarb given by mom this\n. Dose to be increased by 1 mg to 14mg at discharggge.\nPrescription given to parens. Infant to have f/u with neuro\n.\n#3O: in most of . Mtg. with social worker and\nfellow to discuss going home . Phenobarb sheet given to\nthe . had many ?. Bath given and they\nviewed Infant CPR and Obstructed Airway tape.\n#4O: Ad lib demand, breast fdg. well q 1- 2 1/2 hrs.\nVoiding and stooling.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-11 00:00:00.000", "description": "Report", "row_id": 1853128, "text": "NPN\nInfant bottled 160cc with Nuk nipple x1. Slept comfortably through the night. No signs of seizure activity. Sat remained >95%. Mom called for update. Infant ready to be dicharged home.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-11 00:00:00.000", "description": "Report", "row_id": 1853129, "text": "NICU Nursing Discharge Note:\nInfant examined by and MD and cleared for discharge. Parental instructions reviewed w/mom and dad. Infant nursed well then was placed correctly in car seat. Appropriate forms signed and infant discharged with at 10AM.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-11 00:00:00.000", "description": "Report", "row_id": 1853130, "text": "Neonatology Attending Note\n\nNo new events overnight. No seizure activity, stable on maintenance phenobarbital. Will proceed with discharge plans. Neurology follow-up has been arranged. Please see dictation and bedside chart for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-09 00:00:00.000", "description": "Report", "row_id": 1853122, "text": "Nursing progress note\n\n\n#1 O: Temp stable on heated warmer. Baby was sleepy at start\nof shift but has become more active & alert. A: AGA. P: Cont\nto assess.\n#2 O: Quietly alert. No seizure activity noted. Baby had\nrepeat EEG this AM & had MRI done. Remains on phenobarb. A:\nResolving seizures. P: Cont to assess.\n #3 O: in to visit & feed baby. met with\nNeurologist at bedside after MRI was done. A: Involved\n. P: Educate & support.\n#4 O: NPO at start of shift with IV infusing. After MRI was\ndone, baby breast fed well & IV was heplocked. DS 85. Abd\nsoft with active bowel sounds & no loops. Voiding &\nstooling, no spits. A: Breast feeding well. P: Cont to\nassess.\n#5 O: Blood cultures neg to date. Antibiotics d/c'd. Remains\non acyclovir. A: Stable. P: Cont to assess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-10 00:00:00.000", "description": "Report", "row_id": 1853123, "text": "NPN\n\n\n#1 Infant swaddled on off warmer with stable temp.\nSleeping quietly between cares. Active and alert with\ncares. Slightly hypotonic.\n\n#2 No seizure activity noted. Remains on phenobarb with\nlevel sent tonight--30.4. Infant active and alert, but\nslightly hypotonic.\n\n#3 in at 9pm to feed infant. Mom independent with\nbreastfeeding. Reviewed signs of sick infant, when to call\nthe Dr., and preventing infection wih . Infant will\nbe followed by EIP. Parent could use a bath prior to\ndischarge. He will also need hep B vaccine.\n\n#4 Infant breastfed fair at 9pm--he was a little sleepy.\nHe awoke at 12:30am and bottled 180cc of BM20/E20. Small\nspit after breastfeeding. Abd benign. Voiding and\nstooling--guiac neg stool. Wt 4305(+25gms).\n\n#5 Ampi and gent d/c'd earlier in the day. IV infiltrated.\n Acyclovir d/c'd.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-10 00:00:00.000", "description": "Report", "row_id": 1853124, "text": "Neonatology Attending Note\nDay 5\n\nRA. RR30-40s. No A&Bs. No seizure activity. Mean BP 83/45, mean 64. Wt 4305, up 25 gms. BF/PO ad lib (180+cc/k). d/s 104. nl voiding and stooling. Temps stable in open crib. On maintenance phenobarb of 30.4.\n\nMRI - +subarachnoid bleeding\nEEG - Check formal report\n\nNeurology ok w/ discharge planning and follow-up in 1 week at center and continued phenobarb maintenance. Continue parent teaching. Re-check hearing screen. Will need to check HSV PCR. Anticipate d/c in am.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-09 00:00:00.000", "description": "Report", "row_id": 1853118, "text": "NPN 1900-0700\n\n\n1. G/D: Temps stable nested on servo-controlled warmer.\nAlert and active with cares. Settles well in between cares.\nLike his pacifier. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n2. Neuro: Infant appropriate with cares. No seizure\nactivity noted thus far. Infant fixes and follows.\nMaintenance dose of phenobarb started at . EEG\nscheduled for this am at 0700. MRI also scheduled for this\nam at 0900. P: Cont. to monitor.\n\n3. Parents: Mom and Dad were up for cares. Needed some\nverbal cueing with diaper change and breast/bottle feeding.\nObserved while this RN gave phenobarb PO. Updated at\nbedside on infant's condition and plan of care. Asking\nappropriate questions. Will be up this am at 0430 for\ncares. Loving, involved parents. P: Cont. to support and\nupdate parents and set up neuro meeting for later this week\nafter results are back.\n\n4. FEN: Weight is 4280 gms up 35 gms. TF remain at a min of\n80 cc/kg/day. Infant breastfed well at , bottled 100 cc\nat 0000 and then 60 cc more at 0230 with good coordination.\nTolerating feedings well; abd exam benign, and no spits.\nInfant will be NPO at 0500. IV fluids of D10 with 2 mEq of\nNaCl and 1 mEq of KCl will be started at 80 cc/kg/day. D/S\n75. P: Cont. to support nutritional needs.\n\n5. Sepsis: Infant remains on ampi and gent. 48 r/o will be\nfinished this afternoon pending BC results. Infant remains\non acyclovir. No s/s of infection. P: Cont to administer\nabx, follow BC results, and monitor for s/s of infection.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-09 00:00:00.000", "description": "Report", "row_id": 1853119, "text": "NICU Fellow Exam Note\nGEN: Comfortable, No distress\nHEENT: AFSF, MMM\nChest: CTA B\nCV: RRR, no murmur noted\nABD: Soft, NT +BS\nExts: CR< 3sec\nNeuro: no evidence of seizures, tone near normal\n" }, { "category": "Nursing/other", "chartdate": "2175-02-09 00:00:00.000", "description": "Report", "row_id": 1853120, "text": "Neonatology Attending Note\nDay 4\n\nRA. No desats. RR40-60s. HR 110-150. Mean BP 44. Wt 4280, up 35 gms. NPO since 5 am for MRI. TF 80 D10 w/ 2,1. d/s 75. Prior to NPO BM/E20 ad lib. On amp/gent/acyclovir. Maintenance phenobarbital last pm. No additional seizure activity.\n\nEEG done this am.\nAwaiting MRI later today.\n\nA-Plan:\n1. d/c amp/gent\n2. Follow-up neuro studies.\n3. Allow to resume feeds once MRI done.\n4. Continue phenobarb.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-09 00:00:00.000", "description": "Report", "row_id": 1853121, "text": "SOCIAL WORK\nMet with parents this am. They are cautiously pleased with the results of tests that have come back and hope that the seizure issue will resolve itself sooner rather than later. Mum describing how this experience can feel overwhelming at times and she appreciates her husband's calm and positive approach to the situation. Parents requesting help with lodging in the area and have been able to secure two nights (Fri and Sat) in a local hotel at reduced rates. Will place paperwork that they need to complete at the bedside and will collect in the am. Overall parents appear to be taking in and making good use of information offered to them. Eager to hear results of any remaining outstanding tests in a family meeting tentatively sched for and hopeful that newborn can be d/c'd to them in the near future. Adjusting to NICU experience. Will continue to follow. Please call with questions/concerns. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853114, "text": "Neonatology Attending Note\nTerm male, d3, being evaluated for seizure activity.\n\nLast pm w/ some seizure activity necessitating 10 mg/k additional phenobarbital. Started yesterday with 20 mg/k bolus. Otherwise in RA. RR30s. NPO. TF at 80 w/ D10 and lytes. Nl voiding and stooling. On amp/gent and acyclovir.\n\nNeurology is following with us.\n\nPlan:\n1. Begin enteral feedings.\n2. Check phenobarbital level.\n3. Amp and gent pending cx results.\n4. Acyclovire pending HSV PCR for CSF.\n5. MRI/MRA in next day or so.\n6. Follow-up EEG prior to MRI.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853115, "text": "NICU Fellow Exam Note\nGEN: Comfortable, eyes open in Mom's arms\nHEENT: AFSF, MMM\nChest: CTA B\nCV: RRR\nABD: Soft, NT, ND +BS\nEXTS: CR< 3 sec\nNeuro: Tone near normal, no evidence of seizures in last 12 hours\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853116, "text": "NPN 7a-7p\n\n\n1) Infant alert and active with cares. Sleeping well between\ncares nested with boundaries. Cries appropriately with\npainful procedures. Comforts with pacifier. Newborn screen\nsent off. Circ site with less redness. healing nicely.\nVaseline applied with diaper cahnges. Temps stable on\nwarmer. Continue to support dev needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853117, "text": "NPN cont'd\n\n\n2) No tonic clonic seizures seen thus far today. Phenobarb\nlevel 29.8 . Starting on a maintenance dose tonight QD.\nAwake and alert with cares. Fixes and follows. MRi to be\ndone at 9am tomorrow at . EEG to be repeated at 7am.\nContinue to closely follow.\n3) parents up to visit several times. Asking lots of\nquestions. plan and update given. mom held and BF infants.\nPlan to arrange meeting with neuro once all test results\nback . Continue to support.\n4) Min TF 80cc/kg. IVF hl'd at 11am . Bottled 50cc after\nBF'ing well and BF great at 4pm not needing to be\nsupplemented. Voiding well. Small stool. Abdomen benign. No\nspits. D-stick 72 off IVF. infant to be npo at 5am for MRI.\nWill start ivf in the am. continue to asess.\n5) Infant remains on iv ampi and gent. Will rule out\ntomorrow. Cultures pending. Remain on acyclovir. PCR\npending. No signs of sepsis. Continue to asess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-07 00:00:00.000", "description": "Report", "row_id": 1853110, "text": "Nsg admit and progress note 12-7p\n infant transfered from newborn nursery for ? of 3 seizures.Shortly after arrival infant had seizure like activity. tonic clonic movements of right arm and leg lasting 4-5 min. Infant desat to 70\"S and needing bloby. 2nd seizure again at 1pm very similar but without vss changes or desat. Neuro consulted. Bloodwork drawn CBC ,blood cx and electrolytes. All wnl. Cx pending. started on ampi, gent and acyclovir. Phenobarb bolus given and no seizures seen since. Head CT , LP and eeg done. Results pending. RR 30's and no apnea or desats this evening. Blood gas and ion ca done and fine. No murmur . Vss. temps stable on open warmer. Remains NPO . IV placed. IV invusing D10W 2nacl and 1kcl at 80cc/kg. Infant initially with dry mucous membranes. Improved after ivf. Vomited bile X 1 after 1st seizure. Dstick 62. Infant irritable with cares but sleeping in between. Very exaggerated moro reflex. Loves paci. Parents up to visit and updated. Mom held this afternoon. Sw saw family for support. Mom dc'd today and is to stay over in the extra parent rooms. Parents asking a lot of appropriate questions. plan to set up a meeting with parents and neurolgy tomorrow. Mom is a special ed teacher and has a lot of children with seizures which she has stated has increased her anxiety.\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853111, "text": "1 G/D\n2 Neuro\n3 Parent\n4 FEN\n\nREVISIONS TO PATHWAY:\n\n 1 G/D; added\n Start date: \n 2 Neuro; added\n Start date: \n 3 Parent; added\n Start date: \n 4 FEN; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853112, "text": "NPN 1900-0700\n\n\n1. G/D: Temps stable on servo-controlled warmer. Alert and\nactive with cares. Irritable. Likes his pacifier. MAEW.\nAFSF. AGA. Appropriate with cares. P: Cont. to support\ndevelopmental needs.\n\n2. Neuro: Infant had two incidents of seizure activity.\nTonic clonic movements of the right hand and foot were noted\nat 2100 and 2140, lasting mintes, no change in VS. (\nand MD aware). A second bolus (10cc/kg/day of phenobarb was\ngiven). A repeat EEG will be done tomorrow. P: Cont. to\nmonitor for seizure activity.\n\n3. Parents: Dad has been up throughout the night for\nupdates. Mom was discharged today and they are staying in a\nfamily rm on 5 fld ext 7-6121. Asking appropriate\nquestions. Was informed by MD about events of this evening.\nLoving, invested parents. P: Cont. to support and update\nparents and set up fam mtg today ?\n\n4. FEN: Weight is 4245 gms up 60 gms. Infant remains NPO.\nTF of 80cc/kg/day of D10W with 2 mEq of NaCl and 1 mEq of\nKCL are running through a patent PIV. Abd soft, round,\nhypoactive - active BS, and no spits. D/S 90. UO for past\n8 hours has been 1.2 cc/kg/hr. Infant stooled x 1. Circ\nsite intact. P: Cont. to support nutritional needs.\n\n5. Sepsis: Infant remains on ampi/gent/acyclovir. Temps\nstable and infant acting appropriate. CBC normal. BC\npending. P: Cont. to administer abx and monitor for s/s of\ninfection.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-02-08 00:00:00.000", "description": "Report", "row_id": 1853113, "text": "5 Sepsis\n\nREVISIONS TO PATHWAY:\n\n 5 Sepsis; added\n Start date: \n\n" }, { "category": "Radiology", "chartdate": "2175-02-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 751982, "text": " 1:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 36 hour old newborn male infant with new onset seizures. Has\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with full term male, vaccum assited delivery\n REASON FOR THIS EXAMINATION:\n 36 hour old newborn male infant with new onset seizures. Has had 5 seizures\n localized to the right side in last 4 hours.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Full-term male. Vacuum-assisted delivery. New onset of\n seizures.\n\n TECHNIQUE: Contiguous axial scans were obtained from skull base to the\n vertex.\n\n FINDINGS:\n\n There is a very thin high-attenuation subdural hematoma overlying the\n posterior and medial aspects of the right occipital lobe and the adjacent\n inferior parietal lobe. There is a questionable small amount of hemorrhage in\n the right occipital pole. A small amount of high-attenuation hemorrhage is\n seen in both sylvian fissures, within the subarachnoid space. There is no\n intraventricular hemorrhage. The brain parenchyma is otherwise normal. There\n appears to be mild diastasis of the left lambdoidal suture with left parietal\n scalp soft-tissue swelling.\n\n IMPRESSION:\n\n 1) There is a small right occipital subdural hemorrhage without mass effect.\n\n 2) There is a small amount of subarachnoid hemorrhage seen in both sylvian\n fissures.\n\n 3) There is a possible small parenchymal hemorrhage in the right occipital\n lobe.\n\n" }, { "category": "Radiology", "chartdate": "2175-02-09 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 752146, "text": " 11:14 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: PT needs an MRI, MRA, MRV per neurology, Pt is a full term m\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with rightside focal tonic clonic seizures, full term male with evidence\n of blood on CT scan. Need to rule out clot in vasculature\n REASON FOR THIS EXAMINATION:\n PT needs an MRI, MRA, MRV per neurology\n Pt is a full term male newborn with rightside focal seizures with blood on CT\n scan. Will need MRI to rule out clot in vasculature\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right sided focal tonic clonic seizures.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted brain imaging with diffusion\n weighted scans.\n\n FINDINGS: There is a small area of restricted diffusion within the left\n frontal lobe white matter, felt to be consistent with an acute infarct. There\n is no other intracranial pathology detected other than hyperintensity in the\n vertex portion of the scan, on T1 weighted images, raising the possibility of\n segmental occlusion of the superior sagittal sinus. No other abnormality is\n seen.\n\n MR ANGIOGRAPHY OF THE CIRCLE OF AND ITS TRIBUTARIES:\n\n TECHNIQUE: 3D TOF imaging with multiplanar reconstructions.\n\n FINDINGS: The study appears within normal limits.\n\n MR VENOGRAPHY OF THE BRAIN:\n\n TECHNIQUE: 2D TOF imaging with multiplanar reconstructions.\n\n FINDINGS: The images are of limited quality but appear to show patency of the\n major venous structures.\n\n COMMENT: This examination was interpreted in conjunction with Dr. \n , Chief of Neuroradiology at .\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-09-10 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1201205, "text": " 6:09 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-surgical mapping\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with hx of low grade glioma\n REASON FOR THIS EXAMINATION:\n pre-surgical mapping\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Planning for surgery likely low-grade glioma.\n\n COMPARISON: MR of the head done on .\n\n TECHNIQUE: MR of the head post-contrast limited sequences for surgical\n planning.\n\n FINDINGS:\n\n The previously noted left frontal lobe lesion, hypointense in appearance is\n redemonstrated for surgical planning. No significant mass effect. No\n hydrocephalus.\n No obvious new lesions are noted.\n The imaged paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n\n Demonstration of moderate-sized hypointense lesion in the left frontal lobe,\n with few adjacent vessels around/coursing within, for surgical planning. No\n significant mass effect. No hydrocephalus.\n\n" }, { "category": "Radiology", "chartdate": "2200-09-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1201275, "text": " 1:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 31 year old woman with left frontal tumor s/p resection. \n Admitting Diagnosis: RIGHT TUMOR FRONTAL/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with left frontal tumor s/p resection. eval post op\n REASON FOR THIS EXAMINATION:\n 31 year old woman with left frontal tumor s/p resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RJab WED 7:44 PM\n Recent left frontal craniotomy with expected postoperative changes including\n fluid, small amount of blood and pneumocephalus at the surgical resection bed\n as well as extra-axial pneumocephalus. Surrounding edema and mass effect is\n unchanged from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female status post left frontal tumor resection.\n Evaluate post-operatively.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: MR of the head with contrast from .\n\n FINDINGS: There has been a recent left frontal craniotomy with fluid, a small\n amount of hemorrhage and pneumocephalus in the resection bed, as expected.\n There is also a moderate amount of extra-axial pneumocephalus. Residual edema\n and mass effect is unchanged from prior study. There is no evidence of any\n other foci of hemorrhage or any infarction. The visualized paranasal sinuses,\n mastoid air cells and middle ear cavities are clear.\n\n IMPRESSION: Status post recent left frontal craniotomy with expected\n post-operative changes including fluid, small amount of blood and\n pneumocephalus at the resection bed, as well as extra-axial pneumocephalus.\n Extent of surrounding vasogenic edema and mass effect is unchanged from\n pre-operative MR study.\n\n" }, { "category": "Radiology", "chartdate": "2200-09-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1201276, "text": ", M. NSURG SICU-B 1:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 31 year old woman with left frontal tumor s/p resection. \n Admitting Diagnosis: RIGHT TUMOR FRONTAL/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with left frontal tumor s/p resection. eval post op\n REASON FOR THIS EXAMINATION:\n 31 year old woman with left frontal tumor s/p resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Recent left frontal craniotomy with expected postoperative changes including\n fluid, small amount of blood and pneumocephalus at the surgical resection bed\n as well as extra-axial pneumocephalus. Surrounding edema and mass effect is\n unchanged from prior study.\n\n" }, { "category": "Radiology", "chartdate": "2200-09-11 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1201365, "text": " 8:23 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 31 year old woman with left frontal tumor s/p resection. \n Admitting Diagnosis: RIGHT TUMOR FRONTAL/SDA\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with left frontal tumor s/p resection. eval post op\n REASON FOR THIS EXAMINATION:\n 31 year old woman with left frontal tumor s/p resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:59 PM\n expected postsurgical change, minimal midline shift to the right by 5 mm. No\n infarction.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with left frontal tumor after resection.\n\n TECHNIQUE:\n Axial T1 pre- and post-contrast, axial T2, axial FLAIR, axial susceptibility,\n axial DTI, axial, sagittal MP-RAGE sequences as well as sagittal T1 images of\n the head were acquired.\n\n COMPARISON: CT of the head from , MRI of the head from , , CT head from , MRI and MRA of the brain from , .\n\n FINDINGS:\n\n The patient is status post left frontal craniotomy with expected post-surgical\n findings including extra-axial left frontal pneumocephalus, small amount of\n blood products and dural enhancement at the resection site.\n No is a small area of postsurgical decreased diffusion surrounding the\n resection cavity, evidence of infarction. There is mild edema with minimal\n shift of normally midline structures to the right by about 5 mm, unchanged\n from the CT from the day before.\n There is mild mass effect on the left lateral ventricle.\n\n\n There is no intracranial herniation. The flow voids of the partially\n visualized intracranial arteries are preserved.\n\n The paranasal sinuses and the mastoids are clear.\n The orbits are normal.\n\n IMPRESSION:\n 1. Expected post-surgical findings including small extra-axial left frontal\n pneumocephalus, small amount of blood products and dural enhancement at the\n resection site, similar to the postsurgical CT from the day before.\n 2. No territorial infarction and no intracranial herniation.\n (Over)\n\n 8:23 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 31 year old woman with left frontal tumor s/p resection. \n Admitting Diagnosis: RIGHT TUMOR FRONTAL/SDA\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2159-05-04 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 827425, "text": " 10:51 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: HYPERBILIRUBINEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant 5 days old with new onset of oxygen need\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Infant, five days old, now requires oxygen. Study has been\n performed to rule out pneumonia.\n\n TECHNIQUE: Frontal projections of the chest have been obtained.\n\n COMPARISON: There is no prior comparison available at this time.\n\n FINDINGS: The cardiomediastinal silhouette appears normal. The lungs are\n clear. There is no evidence for an effusion infiltrate or pneumothorax.\n\n The visualized portion of the abdomen showed nonspecific gas without any\n evidence for obstruction or ileus.\n\n Limited evaluation of the bones are unremarkable. The venous line is in the\n right atrium.\n\n The visualized portion of the abdomen has nonspecific bowel gas. Limited\n evaluation of the bones are unremarkable.\n\n IMPRESSION: No evidence for pneumonic process. Minor atelectasis noted in\n the right upper lobe and in the left lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2159-05-11 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 828104, "text": " 12:01 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: Assess esophageal probe position for pneumogram\n Admitting Diagnosis: HYPERBILIRUBINEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Term infant with oxygen requirement\n REASON FOR THIS EXAMINATION:\n Assess esophageal probe position for pneumogram\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n A single film was done to check for placement of a pH probe. The probe ends\n at the junction of the middle and distal thirds of the esophagus. The exam is\n otherwise normal.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-11 00:00:00.000", "description": "Report", "row_id": 1978196, "text": "Neonatology Attending Note\nDay 12\nCGA 39 2\n\nNC 13-50cc. RR30-40s. Cl and = BS. No A&Bs. No murmur. HR 130-150s. Mean BP 55.\n\nWt 2675. down 10. PO ad . BF + BM24.\n\nIn open crib.\n\nA/P:\n-- pneumogram today\n-- cont synthroid\n-- cont to monitor cardioresp status with attempts to wean O2 as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2159-05-10 00:00:00.000", "description": "Report", "row_id": 1978194, "text": "#1 - RESP: Remains in NC 100% (50-100cc's). RR ( 30-40).\nLungs clear and equal. No retractions. Breathing\ncomfortably. No apnea or shallow breathing noted. No bradys\nnoted. ? why the need for the O2. Pneumogram planned for\n. night. Mother aware.\n#2 - F&N: ad demand feeder with of 80cc's/kilo. Mom\nhere throughout the day breastfeeding. Baby doing great.\nWakes every 3 hours BF well for 15-20 . ABdominal exam\nbenign. Voiding and . Guiac neg. Baby has not had\nweight gain since birth. Plan to continue breastfeeding\nduring the day and add Enfamil powder 24 cals - for the\novernoc bottling. Mother aware.\n#3 - : Last on wednesday 7.6/0.3. (Rebound)\nsilghtly jaundice. Voiding and . Eating well.\n#5 - G&D: Temp stable in open crib. Alert and active. MAE.\nAFSF. Bottling or breast feeding all feeds.\n#6 - PARENTS: Mom in through out the day. Updated at the\nbedside. Independent with cares. AT times overwhelmed with\nall the recent information. REassured mother. ATtending\nspoke with mother at bedside. Seems more calm this\nafternoon.\n#7 - ENdocrine: Remains on synthroid qd. Call into\nendocrinology about could the need for O2 and poor weight\ngain be related to his congenital hypothyroidism. PLAN:\nincrease cals during bottle feeds overnoc and pneumogram \nnight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-11 00:00:00.000", "description": "Report", "row_id": 1978195, "text": "NPN 1900-0700\n\n\n1. RESP\nO: Remains in NCO2 100% 13-50cc flow, mostly 25cc this\nshift. Breathing 30-40s, sats 95-99%. Occ QSR drifts to mid\n80's noted. LS clr/=. No retractions. No bradys. Pneumogram\nscheduled for today. A: Stable in current resp support. P:\nCont to monitor for s/s resp distress, wean flow as\ntolerated.\n\n2. FEN\nO: BW 2895g. Current wgt= 2675g (-10). Ad feeder w/TF\n 80cc/kg on demand schedule. TFI x24hrs= 66cc/kg/d plus\nBF'ing all day (x4). Bottled 55-70cc of BM24/E24 q3-4h\novernight. Abd exam benign. No spits. Voiding and \n(heme-). Small reddened area beginning around anus, will\norder Desitin. A: Tolerating feeds. P: Cont to monitor wgt\ngain, FEN status.\n\n5. G&D\nO: is alert/active with cares. Waking q3-4h for\nfeeds. Sleeps well b/w care times. Temps stable swaddled in\nOAC. ,. Loves pacifier. Brings hands to face. A: AGA.\nP: Cont to provide dev appropriate care.\n\n6. PARENTS\nNo contact w/family thus far this shift. Unable to assess.\n\n7. ENDOCRINE\nO: Infant with h/o abnormal thyroid levels/function.\nReceiving Synthroid as ordered. Seen by Endocrine this week,\nwill contact re:O2 ,poor wgt gain, etc. A: Infant\nw/possible congential hypothyroidism. P: Cont to monitor for\nchanges in exam.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-11 00:00:00.000", "description": "Report", "row_id": 1978197, "text": "Nursing Progress Note:\n#1 - RESP: Remains in NC (13-25cc's). RR (30-50). Lungs\nclear and equal. O2Sats 94-100%. Less labile today with\nSats. No drifts or Bradys. Pneumogram being done - started\nat ~noon.\n#2 - F&N: Ad demand feeder. Breastfeeding during the\nday. Fed 3 times well. 15-20min long each time. Po feeding\novernoc with BM24 with enf powder to help with weight gain.\nAbdominal exam benign. Voiding and with each diaper\nchange. Buttocks red - desitin applied.\n#5 - DEV: TEmps stable in open crib. Alert and active with\ncares. MAE. Waking for feeds. All po.\n#6 - PARENTS: Mom in the entire day. Independent with cares.\nUpdated at the bedside. Mom should be taught how to give the\nsynthroid . Please give during the day with breastmilk.\n#7 - ENdocrine: Father spoke with endocrine at .\nMade follow up appointment for 1pm at .\nContinue SYnthroid qd. Change time to days for mom to give.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-11 00:00:00.000", "description": "Report", "row_id": 1978198, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\ncomfortable respirations in NCO2, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft\ngood tone\n" }, { "category": "Nursing/other", "chartdate": "2159-05-12 00:00:00.000", "description": "Report", "row_id": 1978199, "text": "NPN 7p-7a\n\n\nResp: Rec infant in NC 100% 13cc flow. Infant trialing in RA\nsince 0300. Ls clr/=. No bradys or spells so far this shift.\nPnemogram completed at 2400. RR 40-50's. Cont to monitor.\n\nFen: Wt 2.665kg (-10gms). Conts on tf of 80cc/kg of e24/\nbm24 with enf powder. infant po'ing 70-80cc. Intake for\n24hrs. 95cc/kg +bf. NO spits. Voiding and with each\ndiaper change. Quaic neg. Bottom sl exoriated desitin\napplied.\n\nDev: Temp stable swaddled in open crib. Alert and active\nwith cares. Wakes for feeds. Well coordinated with po feeds.\nCont to support developmental milestones. Cont with current\nplan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-12 00:00:00.000", "description": "Report", "row_id": 1978200, "text": "NPN 7p-7a\n\n\nParenting: No contact from so far this shift.\n\nEndocrine: Infant conts on synthroid as ordered. To be given\nby MOm today. Await plan per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-12 00:00:00.000", "description": "Report", "row_id": 1978201, "text": "Neonatology Attending\nDOL 13 / CGA 39-3/7 weeks\n\nRemains in NC to maintain SaO2 94-98% (saturation limits were transiently reduced to 90%). Pneumogram results: no prolonged central apnea, frequent desaturation with short central apnea and periodic breathing (for 4.6% of sleeping time); no bradycardia or reflux.\n\nNo murmur.\n\nWt 2665 (-10 for the fifth day) on TFI 80 cc/kg/day BM24 in addition to breastfeeding (intake 95 cc/kg/day yesterday). Voiding and normally. Abd benign.\n\nA&P\n37-4/7 wk GA infant with congenital hypothyroidism\n-Given pneumogram results, we will start caffeine today and continue attempts to wean supplemental oxygen\n-Continue on current caloric density with close monitoring of weight\n" }, { "category": "Nursing/other", "chartdate": "2159-05-10 00:00:00.000", "description": "Report", "row_id": 1978191, "text": "NPN 1900-0700\n\n\n1. RESP\nO: Remains in NCO2 100% 25-50cc (mostly 25cc). Not trialed\noff this shift. Breathing 20s-50s, sats 92-99%. No desats\nnoted thus far this shift. No retractions or ^ed WOB noted.\nLS clr/=. ?Obtain pneumogram on Friday if desats/O2 req\ncontinue. Last desat yesterday to 70% (during trial off O2).\nA: Stable in current resp support. P: Cont to monitor for\ns/s resp distress, wean flow as tolerated.\n\n2. FEN\nO: BW 2895g. Current wgt= 2685g (-15). Ad demand feeder.\nTFI x24hrs= 68cc/kg/d + BF'ing during entire day shift (x4).\nBottling 60-70cc of BM20/E20 q3h overnight. Bottling w/\nbottle per Mom's request. Abd exam benign. No spits. Voiding\nand sm amt yellow each care. A: Tolerating feeds.\nP:Cont to monitor intake, FEN status, wgt gain.\n\n5. G&D\nO: is alert/active with cares. Wakes q3h for feeds.\nGenerally sleeping well b/w feeds. Temps stable swaddled.\nMoved from warmer to crib this shift. Loves pacifier. Brings\nhands to face. A: AGA. P: Cont to provide dev appropriate\ncare.\n\n6. PARENTS\nNo contact w/family thus far this shift. Unable to assess.\n\n7. ENDOCRINE\nO: Receiving Synthroid as ordered. Seen by Endocrine team\nyesterday. Met w/parents @ bedside. TSH and other labs sent\nthis week. A: Infant w/abnormal thyroid function. P: Cont to\nmonitor for changes in exam, administer Synthroid as\nordered.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-10 00:00:00.000", "description": "Report", "row_id": 1978192, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: alert infant in open crib, nasal cannula O2\nSkin: warm and dry; color pink; mild jaundice\nHEENT: anterior fontanel open, level; sutures open\nChest: breath sounds clear/=\nCV RRR without murmur; normal S1 S2; pulses +2/=\nAbd: soft; no masses; + bowel soudn\nGU: circ healed; testes descended\nExt; moving all\nNeuro: appropriate tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2159-05-10 00:00:00.000", "description": "Report", "row_id": 1978193, "text": "Neonatology Attending Note\nDay 11\nCGA 39 1\n\nNC 25-75cc. Cl and = BS. RR20-40s. Will sat drift but no A&Bs. BP 70/24, 39.\n\nWt 2685, down 15. TF 80 cc/k/day po ad , +BF. Nl voiding and .\n\nIn open crib.\n\nA/P:\nFT infant with congenital hypothyroidism, resolving . Continues with unexplained O2 req and poor overall weight gain to date.\n\n-- inc cals to 24 for the evening feedings\n-- will proceed w/ pneumogram to assess central respiratory drive, possibility of immature resp pattern\n-- discussed medical plan w/ mother at bedside\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-09 00:00:00.000", "description": "Report", "row_id": 1978187, "text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in low flow nasal cannula, requiring\n13-50cc flow. RR 20-40's. Lung sounds are clear. No\nspells/desats noted. Will monitor.\n\n2. F&N: Pt remiasnon TF of 80cc/k/d of BM20 on ad \nschedule. Total intake was 64cc/k/d yesterday plus 4 strong\nbreastfeeding sessions for >10 minutes each. Abd benign.\nBS+. Nos pits noted. Voiding well and passed one small\nstool. Weight loss 20 grams.\n\n3. BILI: Rebound bili level pending. Will monitor. Pt\ndoes not appear significantly jaundiced.\n\n5. DEV: is active and alert during his cares. He\nwakes Q 4 hours to eat. Sucks vigorously on pacifier and\nputs his hands to his face.\n\n6. PAR: Parents in to do cares at . Mom with\nbreastfeeding and Dad administered pt's Synthroid.\n\n7. ENDO: Pt is on Synthroid. T4, free T4 and TSH levels\npedning. Will monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-09 00:00:00.000", "description": "Report", "row_id": 1978188, "text": "Neonatology Attending Note\nDay 10\nCGA 37 4\n\nRA since this am. RR20-40s. Cl and = BS. HR 110-150. Pink and well perfused. Yest at 4:00 a desat to 82 with recorded periodic /breathing and apnea.\n\nBP 62/42, 49.\n\nReb bili 7.6/0.3.\n\nWt 2700, down 20 gms. TF po ad 80. BM20 + BF. Nl voiding and .\n\nTFTs: TSH > 100/T4 10.1/Free T4 1.5.\n\nSwaddled in open crib.\n\nFamily meeting at 4:00.\n\nA/P:\n-- needs to be observed for 5 days post last event. Trend is improving, If fails to show steady improvement or multiple recurrent events, will consider pneumogram and methylxanthine therapy.\n-- resolving\n-- review TFTs with endocrine\n-- family meeting today\n" }, { "category": "Nursing/other", "chartdate": "2159-05-09 00:00:00.000", "description": "Report", "row_id": 1978189, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. pink, jaundiced. Abd benign, no HSM. Active bowel sounds. Infant active and alert with exam.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-09 00:00:00.000", "description": "Report", "row_id": 1978190, "text": "NPN \n\n\n\n 1. Infant remains in NC 100% 25cc flow. Trialed infant out\nof oxygen this am. During BF and after BF while supine in\nthe crib. He desated to 79-88% not correcting himself having\nshallow or periodic breathing. Once back in O2 has not had\nsig desats but does cont to drift to the high 80's. LS cl/=.\nNo increased WOB. A: Conts to req O2 to maintain sats after\nfeedings. ?needs pneumogram.\n 2. Infant conts on ad 80cc/k BM 20. He has been BF\nall day. Waking every 2-3hrs today and eagerly BF for\n>10min. Abd soft w/active BS, no spits, voiding and \nheme-. Doing well w/BF.\n 5. Infant has stable temp swaddled in OC. A&A w/cares.\nWakes for feedings. Sleeps between cares. AFSF. MAEW. AGA.\n 6. Family meeting held today w/. Mom spent all day at\nthe bedside. She appears very stressed between leaving her\n2yo at home and not spending enough time in the hospital,\neven though she is here all day. Her in laws are here as\nwell and feels stressed about that. Dad is very supportive\nand is able to decrease her stress level.\n 7. Conts on synthroid. TFT's done yest. Endocrine consult\ndone today. Mom in the room when they came by. Information\nwas given to her. I was not present when they spoke w/mom.\nShe appeared upset after they left, saying they told her\nthat had no thyroid gland. Questions answered in\nmore detail during fam meeting.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978182, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOf. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating feeds. Abd soft, active bowel sounds, voiding and . Stable temp on open warmer. Mom @ bedside. Discussed continuing progress. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978183, "text": "SOCIAL WORK\nTouched base briefly with mother during her visit to the NICU. Mum reviewed events that led to infant's re-admission. Stated that initially she was quite anxious about infant's well being but feels better as each day passes. She is aware that she may feel increased worry re: apnea episode occuring at home when infant is ready for d/c. Encouraged mum to address these concerns with providers. Overall she appeared to have adjusted well to NICU environment.\nProvided reduced parking paperwork for her. Understand family meeting will take place tomorrow afternoon. Will ask LICSW to be available as I will be unavailable until . Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978184, "text": "NPN \n\n\n\n 1. Infant remains in RA. RR 20-50. No increased WOB noted.\nSating >92% w/occas drifts to 86-89% after feedings assoc\nw/shallow breathing pattern. QSR. No desats or A/B's so far\ntoday. LS cl/=. Brady countdown conts. day .\n\n 2. TF ad 80cc/k BM/E20 (38cc q4hr). Infant has been\nBF all day. He BF well for 10min each side q3hrs. Abd soft\nw/active BS, no spits, no loops, voiding and heme\nneg.\n\n 3. Bili lights off at 0600. Infant conts to be jaundiced.\n w/each diaper change. Rebound bili ordered for \nam.\n\n 5. Temp stable swaddled in off warmer. A&A w/cares. Wakes\nfor feeds. MAEW. AFSO. AGA.\n\n 6. Mom at bedside all day. Participating in cares.\nIndependent w/BF. Asking approp questions. Updates on\ninfant's progress given at the bedside. Fam meeting booked\nfor wed 1600.\n\n 7. Infant conts on synthroid. Parents will give dose this\neve. TFT's ordered w/am labs. Endocrine consult pnd.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978185, "text": "NPN addendum\n\n\n\n 1. Infant had 2 desats (82-86%) after BF assoc w/periodic\nbreathing. No brady w/these episodes. Req mild to mod stim.\nto recover.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978186, "text": "NPN addendum\n\n\n\n 1. Infant placed in NC after prolonged drifts in O2 sats to\nthe high 80's. He is in 100% 50cc flow and his sats are now\n97% or above.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978179, "text": "Nursing Progress Note\n\n\n#1. O: Infant remains in RA with O2 sats> 92%. RR 20's-50's.\nBreath sounds are clear and equal. No GFR noted. No spells\nthus far. A: Stable in RA. P: Continue to monitor resp\nstatus.\n\n#2. O: Infant remains po adlidv with 80cc/k/d of BM/E20.\nInfant received 92cc/k/d + BFW x2. No spits. Abd soft and\nflat with active bowel sounds. Voiding and . Wgt is\ndown 25gms tonight to 2720gms. A: po adlib feeds. P:\nContinue to monitor feeding tolerance.\n\n#3. O: Infant remains under single phototherapy. Eye shields\nin place. A: . P: D/C phototherapy this a.m.\nRecheck Rbili .\n\n#5,#7. O: Infant remains on off warmer, under phototherapy\nwith stable temp. Waking for feeds q3-4hrs. Alert and active\nwith cares. Po feeding well. Infant remains on synthroid.\n?Endocrine consult today. A: AGA. P: Continue to assess and\nsupport developmental needs. Hypothyroidism.\n\n#6. O: Parents in this evening. Mom still very emotional.\nParents updated by Dr at bedside. To scheduale\nfamily meeting for Wednesday afternoon. A: Involved parents.\nP: Continue to inform and support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978180, "text": "Neonatology Attending Note\nDay 9\n\nRA since Monday. Occass sat drifts, QSR. Last event req intervention Saturday. BS cl and =. RR20-50s. HR 130-160s. No murmur. BP 69/34, 46.\n\nPhotot d/c'd this am. Reb bili for am.\n\nWt 2720, down 25 gms. TF po ad , 80 (92 + BF). well. Nl voiding and .\n\nOn synthroid.\n\nOn off warmer.\n\nA/P:\nInfant w resolv , resolving O2 need, resolving immature resp pattern.\n\nCont synthroid. Check TFTs in am. Endocrine to see while infant in-house.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-08 00:00:00.000", "description": "Report", "row_id": 1978181, "text": " Nurse Case Manager\nA referral was made to the (phone , fax ) for follow up skilled nursing visits after discharge home. This is the agency that was involved with prior to admission. The baseline medical and demographic information has been called in to (beeper ) liaison RN. She has been given a tentative discharge date of Thursday, . When the discharge date is made definite, please call and notify the agency and fax the completed page 1 and 2 referral forms to the above fax number. The mother is aware of the above referral and is in agreement with the plan of care. If you have any questions, please page me at beeper . The pediatrician is at (phone , fax ).\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-13 00:00:00.000", "description": "Report", "row_id": 1978207, "text": "NICU Nursing Progress Note\n\nRESP\nO: Infant remains in nasal cannula 100% requiring 13-75cc\nflow to maintain O2 sats within parameters of 94-99. Breath\nsounds, resp rate and WOB are at baseline. Remains on\ncaffeine. Resp pattern on monitor and by observation shows\nless periodic breathing and shorter pauses when occurring.\nNo spontaneous desats noted today. O2 requirement increases\nwith feeds and activity.\nA: Persistent O2 requirement following initiation of\ncaffeine. Potential for mild persistent pulmonary\nhypertension.\nP: Monitor and assess.\n\nHYPOTHYROIDISM\nO: Remains on daily dose of synthroid. Small facial rash\nthat was seen on previous shift has subsided.\nA: No evidence of compromise.\nP: Continue treatment.\n\nNUTRITION\nO: Infant breast feeding ad on demand all day as Mom\nvisits. Infant latches on very well, nurses eagerly for >20\nmins each side and sleeps contentedly for 3-4 hrs between.\nDiapers are wet each time and infant stools with each diaper\nchange.\nA: Infant feeding well.\nP: Monitor weight progression and continue plan of offering\n24 cal BM/Enf during the night. Enfamil powder added to BM.\n\nDEVELOPMENT\nO: Infant waking for feeds. Tone wnl. Active and alert for\ncares. Sleeping in long naps. Temp stable in open crib.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom in for the day with Dad joining her intermittently.\nBoth updated regarding infant's status and plan of\ncare. Mom gave infant tub bath and handles infant well. She\nbreastfeeds with confidence and experience and recognizes\ninfant's signals. Dad prepared daily medications for Mom to\nadminister via bottle to infant. Spoke with at\nlength at bedside and explained that infant would most\nprobably be going home on caffeine, synthroid, and a\nmonitor. Mom seemed upset of the thought of a monitor, but\nindicated that this has been discussed before with them.\nA: Involved .\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-14 00:00:00.000", "description": "Report", "row_id": 1978208, "text": "NPN 11p-7a\n\n\n#1: Pt conts in NCO2, 100%/13cc. Infant trialed out briefly\nbut began desating and was replaced back in O2. RR\ncomfortable at 30-40's with no WOB. BS clear and equal\nbilaterally. Pink and well perfused, no spells. Conts on\ncaffiene. A: STable, still 'g sm amt of O2. P: cont with\nplan, wean as tolerated.\n#2: TF 80cc/kg/d of ad feeds. Pt waking on own for\nfeeds, taking in good amts of BM/PE20 - please see flow\nsheet for details. Abdomen is benign, voiding and .\nNo spits or aspirates. A: Tolerating feeds. P: cont with\nplan.\n#5: Temp stable in OAC, fontanelles are soft and flat. Alert\nand active with cares, sleeping well. Infant brings hands to\nface, likes pacifier. Awakens for feeds. A: AGA. P: cont\nwith plan.\n#6: No contact with at this writing.\n#7: Pt conts on synthroid QD as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-05 00:00:00.000", "description": "Report", "row_id": 1978169, "text": "Nursing Progress Note\n\n1 RESPIRTORY\n2 FEN\n3 HYPERBILI\n4 SEPSIS\n5 DEVELOPMENT\n6 PARENTING\n\n#1. O: Infant placed in NC O2 tonight for frequent O2 sat\ndrifts to 60's-70's with apnea and duskyness. Currently\ninfant in NC 100% in 50-75cc's flow. RR 20's-40's. Breath\nsounds are clear and equal. CXR done-results WNL MD. A:\nO2 requirement. P: Continue to ween from O2 as tolerated.\n\n#2. O: PIV started. NS bolus given x1. IVF of D10W with NaCl\ninfusing at 60cc/k/d. Infant also po feeding BM q3hrs. D/S\n111. Abd soft and flat with active bowel sounds. No loops.\nVoiding and stooling loose yellow stools. Wgt is 2640gms\ndown 255 from birth wgt. A: Frequent po feeds. P: Continue\nto encourage feeds.\n\n#3. O: Infant remains under triple phototherapy. Eye \nin place. Repeat bili down to 18.7 from 22.8. A: Hyperbili.\nP: Continue with treatment.\n\n#4. O: CBCD and blood cultures sent due to O2 requirement.\nNo left shift. Infant started on ampicillin and gentamicin.\nA: r/o sepsis. P: Continue to follow cultures.\n\n#5. O: Infant remains on radiant warmer with stable temp. He\nis alert and active with cares. Otherwise sleeping soundly.\nStarted on synthroid last evening. Parents shown how to give\nmed. A: AGA, hypothyroidism. P: Continue to assess and\nsupport developmental needs.\n\n#6. O: Parents up most of evening. Staying in parenting\nroom. Asking lots of appropriate questions. Mom needs much\nencouragement, support and assistance with breastfeeding\ntechniques. A: Involved, very concerned parents. P: Continue\nto inform and support.\n\nREVISIONS TO PATHWAY:\n\n 1 RESPIRTORY; added\n Start date: \n 2 FEN; added\n Start date: \n 3 HYPERBILI; added\n Start date: \n 4 SEPSIS; added\n Start date: \n 5 DEVELOPMENT; added\n Start date: \n 6 PARENTING; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-05 00:00:00.000", "description": "Report", "row_id": 1978170, "text": "Neonatology Attending Note\nDay 6\n\nNC 100%, 75-200cc, overnight this am 13cc. ABG 7.47/34/54/25/1. CXR read as normal by previous team. Apnea and desaturations. No bradys.BS cl and =.\n\nHR 140-150s. No murmur. BP 52/22, 35.\n\nBili 18.7/0.6. Under triple photot.\n\nWt 2640, down 255 from BW. BF/PO q 3hrs. d/s 90-111.\n143/4.2/109/23 from admission.\nIVF at 60 cc/k/day. Nl voiding.\n\nOn synthroid for low T4 on state screen.\n\nOn amp/gent for sepsis rule-out.\n\nOn radiant warmer.\n\nA/P:\nmonitor periodic breathing, wean O2 as tol\ncheck CXR myself\ncont photot, follow bili levels\npo ad , fluids at 80\ncont synthroid, follow TFTs\ncont abx for anticipated 48 hour course, sepsis eval neg to date\nwean to open crib\n" }, { "category": "Nursing/other", "chartdate": "2159-05-12 00:00:00.000", "description": "Report", "row_id": 1978202, "text": "NICU NURSING PROGRESS NOTE\n\nInfant remains in nasal cannula with parameters 94-99 as per\ndiscussion on rounds. Requires 13-50cc flow to mainatin O2\nsats >94. Breath sounds, resp rate and WOB are at baseline.\nPneumogram results reviewed by team and infant given loading\ndose of caffeine 20mg/kg. advised of status and plan\nof care.\n\nRemains on synthroid. Dad administered today's dose.\n\nInfant breast feeding every 4 hrs and latches on well,\nfeeding for >20 mins each side and sleeping well between.\nVoiding and with each diaper change. At 1730,\ninfant not satisfied at end of nursing session and given\nEnfamil supplement to satiate. Abd exam benign.\n\nTemp stable in open crib. Active and alert with cares.\nSleeping well between feeds. Tone wnl.\n\nMom in for entire shift, Dad joining her periodically.\nUpdated at bedside.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-12 00:00:00.000", "description": "Report", "row_id": 1978203, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\ncomfortable respirations in NCOI2, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft\ngood tone.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-13 00:00:00.000", "description": "Report", "row_id": 1978204, "text": "NPN 7p-7a\n\n\nResp: Infant remains in NC 100%. 13-25cc flow. No spells or\ndesats so far this shift. Conts on caffiene. Ls clr/=. No\nretractions noted. Cont to wean 02 as .\n\nFen: wt 2.765kg (+100gms). aware. Conts on 80cc/kg\nof bm 24 with enf powder/e24. Po 801-100cc. Waking q 4-5hrs.\n24hr intake 79cc/kg + bf. Med spit x1. Abd soft. Active bs.\nVoiding with each diaper change. quaic neg. Desitin\napplied. Cont with current plan.\n\nDev: Temp stable swaddled in open crib. Alert and active\nwith cares. Wakes for feeds. Well coordinate with po feeds\nthis shift. Cont to support developmental milestones.\n\nParenting: No contact from so far this shift.\n\nEndocrine: Infant conts on synthroid. Await plan per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-13 00:00:00.000", "description": "Report", "row_id": 1978205, "text": "Neonatology Attending\n\nDOL 14 CGA 39 4/7 weeks\n\nStable in NCO2 25-50cc. Sats 94-99%. Pneumogram with immature breathing pattern, no GER. Caffeine recommended and started last night.\n\nNo murmur. BP 63/30 mean 41.\n\nBreast and bottle feeding. Mother breastfeeds exclusively for of feeds. With other half has taken 79 cc/kg 24 cal. Voiding. (heme neg). DS 80 Wt 2765 grams (up 100).\n\nOn synthroid. TFTs improving.\n\nMother in during the day and up to date.\n\nA: Stable. Immature breathing pattern being treated with caffeine. Now showing some wt gain. Congenital hypothyroidism being treated.\n\nP: Monitor\n Wean to RA\n Home when on caffeine for a few days and stable in RA\n Will need a monitor at home\n Follow TFTs per endocrine.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-13 00:00:00.000", "description": "Report", "row_id": 1978206, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal. nl s1S2, no audible murmur. Pink and well perfused. abd benign, no HSM. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-04 00:00:00.000", "description": "Report", "row_id": 1978168, "text": "NICU Triage Note\n\nID: 5 day old, term male with hyperbilirubinemia, also with hypothyrsoidism. Noted to have episodes of O2 desat and periodic breathing on admission to NICU.\n\nPre/perinatal Hx: Mother is 36 g@ P now 2, EDC , PNS: O+, Ab-, RPRNR, RI,HepBSAg-, GBS-. Benign antepatum course, Pitocin indection, uncomplicated vaginal delivery on = 37 4/7 weeks gestation. routine care in DR, apgars 9 amd 9. BW 2895 gm. No issues in NN, discharged to home at 48 hours. Diagnosed with hypothyroidism by state screen, started on synthroid today. Seen in PMD's office today, bili 19. PMD tried to arrange for home phototx unsuccesfully so admitted through triage to NN for phototx. Baby otherwise doing well, breastfeeding, mother's milk is in, baby is voiding and stooling with each feeding. Mothers blood type is O+, baby A+, DC -.\n\nAdmission PEx Weight 2040 gm. HR 136, RR 40, O2 sat mostly in 90's, occasional drift to low to mid 80's, responsive to BBO2. Nondysmorphic term male, AFSOF, MMM, palate intact, no increased WOB, BS clear/=, RRR without murmur, abd benign without HSM, normal male s/p circ, healing well. Normal back and ext, skin jaundiced, warm and well perfused. Normal tone and responsivity.\n\nA/P: Exagerated physiologic jaundice, possibly exacerbated by breast feeding jaundice, no evidence of hemolysis or primary liver disease. Also with hypothyroidism, asymptomatic, diagnosed on state screen, started on synthroid, doubt role in hyperbilrubinemia.\nAlso with occasional O2 desats and periodic breathing noted when on monitor in NICU. DDx includes sepsis/pneumonia (no perinatal risk factors), dysmature breathing pattern, no evidence of primary cardiac problems. Unlikely to be realted to hypothyroidism.\n\nDraw serum bili, lytes. CBC, blood cx, CXR, observe on monitor, consider pneumogram and possible caffeine tx is sxs persist, antibiotics of lab results or clinical course concerning for sepsis . and I spoke extensively with parents. Will call PMD to provide update.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-17 00:00:00.000", "description": "Report", "row_id": 1978225, "text": "Neonatology Attending\nPneumogram:\n\nMuch improved w/ baseline sats in 97-99% and less frequent drops to the mid 80s.\n\nWill d/c to home tonight on home monitoring and caffeine therapy.\n\nDiscussed TFTs with Endocrine service. Synthroid dose changed to 25 mg 4 x week/12.5 mg 3 x week.\n\nDiscussed new synthroid dose and pneumogram results with mother, who is excited to finally be going home.\n\nd/c t>30'.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-07 00:00:00.000", "description": "Report", "row_id": 1978176, "text": "NURSING PROGRESS NOTE\n\n\n1 - RESP - PT REMAINS ON O2 NC 25CC, 100%. CURRENTLY\nTRIALING OFF O2. NO DESATS, NO A/BS NOTED.\n\n2 - FEN - TF= 80CC/K. PT TAKING IN 102CC/K AND BF WELL\nYESTERRDAY. TAKING E/BM20. PT FEEDS, NO SITS. ABD\nBENIGN. PT VOIDING, . WT=2.745(+30)\n\n3 - - PT UNDER SINGLE PHOTOTHERAPY, EYE SHIELDS\nON. PT SLIGHT JAUNDICE. VOIDING, \n\n4 - SEPIS - ABX DCD. BLOOD CX NEGATIVE.\n\n5 - DEV - TEMP STABLE ON OFF WARMER. ALERT, WAKING FOR\nCARES. AFOF. RECEIVING SYNTHROID AS ORDERED\n\n6 - PARENT - MOM AND DAD IN FOR CARES. LOVING. ASKING\nAPPROP QUESTIONS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-07 00:00:00.000", "description": "Report", "row_id": 1978177, "text": "Neonatology Attending\n\nDOL 8 CGA 38 1/7 weeks\n\nTransitioned to RA last night. In RA with sats >93 with occ drifts to 88%. R 30s-50s. No A/B. Last apnea .\n\nOn 80 cc/kg/d BM/E 20. Took 102 cc/kg yest + BF. Voiding. (heme neg). DS 91 Wt 2745 grams (up 30).\n\nBili 7.7/0.4 on single phototherapy.\n\nOff antibiotics.\n\nOn synthroid.\n\nParents in and up to date.\n\nA: Stable. On countdown. Resolving . Congenital hypothyroidism being treated.\n\nP: Monitor\n Feed ad with max 4 hr interval\n D/C phototherapy in am\n Rebound bili \n Endocrine consult\n Check TFTs with next blood draw\n Home Thurs if no further spells\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-07 00:00:00.000", "description": "Report", "row_id": 1978178, "text": "NPN 0700-\n\n4 SEPSIS\n7 Endocrine\n\n1. Remains in RA with sats 90-100% in prone position.\nLungs clear. RR 30-50's. No A&B's thus far. Day of\nA&B countdown. Stable in RA. Cont to monitor for\nA&B/desats.\n\n2. Infant now on ad demand schedule of BM/E20. . TF\n80cc/k/d= 38cc Q4hr. Abd benign. Voiding and .\nAble to breast fed well twice today and bottled 40cc with\n bottle. Tolerating all po's thus far without emesis.\nWill cont. to monitor ability to take all PO's.\n\n3. Remains under single phototherapy with eye shields on.\nColor is slightly jaundiced. well and taking good\nPO's. Plan to D/C phototherapy in am as per team.\n\n5. Temp stable nested under off warmer. Awake and active\nwith cares, stirs at times for feeds. Rest well inbetween\ncares. MAE, brings hands to face and mouth. Cont to\npromote development.\n\n6. Parents in to visit and updated on plan of care. Mother\nin for first 2 feeding and breast well. Mother independent\nwith infant cares. Parents planning to visit tonight at\n2100. Invested parents. Cont to support, update, and\neducate parents.\n\n7. Infant remains on synthroid as ordered for\nhypothyroidism. Awaiting endocrine consult. Plan to obtain\nthyroid function test on wed. am as per team. Cont to\nreinforce synthroid teaching with parents.\n\nREVISIONS TO PATHWAY:\n\n 4 SEPSIS; resolved\n 7 Endocrine; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-17 00:00:00.000", "description": "Report", "row_id": 1978226, "text": "Nursing Progress Notes.\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, no spells noted. Pneumogram completed at 0845.\nTeaching done with home monitor this am. A: No spells\nnoted. P: Discharge home with monitor and caffeine.\n#2 O: Baby has been feeding ad with breastfeeding or\nBM24/E24. Baby feeds well, no spits, abdomen benign,\nvoiding and . A: Feeding well. P: Discharge home\nwith this evening.\n#5 O; Temp stable in open crib. Baby is and active\nwith cares and wakes to demand feed on his own. Baby sleeps\nwell between cares. A: Appropriate for age. P: Continue to\nsupport development.\n#6 O; in for teaching this morning with the monitor\ncompany and mom was in all day. Mother was updated on\nchanges in synthroid doses and on the results of the\npneumogram. A: Involved family. P: For discharge home this\nevening.\n#7 O; Synthroid dose adjusted and new prescription given to\nmother this afternoon. A: Involved family. P: Discharge\nwith follow up with endocrine clinic.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-17 00:00:00.000", "description": "Report", "row_id": 1978227, "text": "Discharge note\n\n1 RESPIRTORY\n2 FEN\n5 DEVELOPMENT\n6 PARENTING\n7 Endocrine\n\nBoth in to take infant home. Checked tags with mom.\nSigned discharge form and carseat form. Mom breastfed infant\nprior to placing in carseat. Given discharge bag and\nbreastmilk. This RN will fax form. visit scheduled\nfor Saturday. Pedi appt for . Endocrine appt for .\nReviewed medications. Mom has scripts, will fill. Stable to\ndischarge home on apnea monitor.\n\nREVISIONS TO PATHWAY:\n\n 1 RESPIRTORY; resolved\n 2 FEN; resolved\n 5 DEVELOPMENT; resolved\n 6 PARENTING; resolved\n 7 Endocrine; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-16 00:00:00.000", "description": "Report", "row_id": 1978221, "text": "Nursing Progress Notes.\n\n\n#1 O: Baby continues in room air. Breath sounds clear and\nequal, minimal retractions noted. No spells noted.\nPnemogram started at 1900. A: No spells today. P: Continue\nto monitor.\n#2 O: Baby continues to feed ad demand, all\nbreastfeeding today. Baby breastfeeds well usually for over\n30 . Mom brought expressed breastmilk for nighttime use\nand requested that baby receive a little with each feeding.\nAbdomen soft, bowel sounds active, no loops. Voiding well,\nstools guiac negative. A: Feeding well. P: Continue ad \nfeeds.\n#5 O: Temp stable in open crib. Baby wakes to demand feed\nand sleeps well between cares. Car seat screening and\nhearing screen passed. Baby was fussy for a short time this\nevening and then slept well. A: Appropriate for age. P:\nContinue to support development.\n#6 O: Mother in to spend the day with baby. Mother is\nattentive to baby's needs. Mom tearful today. Dad in to\nvisit this evening. A: Involved family. P: Ask Sw to visit\nmom in am.\n#7 O: Baby continues on synthroid. Mother prepared tablet\nand gave it to baby. A: Involved family. P: Check TFT's\nin am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-17 00:00:00.000", "description": "Report", "row_id": 1978222, "text": "PCA Note\n\n\nRESP: Infant remains in RA; O2 sat 96-100%. RR 30-60's. LS\ncl/= with occ. mild subcostal retxns. No desats, no spells\nthis shift. Remains on caffeine. Continue to monitor\nrespiratory status.\n\nFEN: BW 2895. Current weight tonoc 2845; up 40g. Infant\nis on an adlib/demand schedule of BM24 with enfamil powder.\nInfant is bottling Q2-4hrs taking 80cc with 20-25cc snacks.\n took in 61cc/k with good BF during the day. Abd.\nbenign - soft, round, +BS, no loops. Voiding and ;\nheme trace positive x1. Desitin applied for small diaper\nrash. Retic and crit drawn this shift, results pending.\nContinue to encourage PO'S.\n\nDEV: Infant swaddled in OAC. Temps stable. Alert and\nactive with cares. Waking about Q2-4. Enjoys being held.\nMAE. Pneumogram being done this shift. Continue to support\ndevelopmental needs.\n\nPARENT: No known contact this shift from . Continue\nto support and update as needed.\n\nENDOCRINE: Infant remains on synthroid. Infant stable.\nTFT to be done this morning. Continue to monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-17 00:00:00.000", "description": "Report", "row_id": 1978223, "text": "PCA Note\nI have examined this infant and agree with note and assessment of PCA, Tran.\n\nD-stick 73. Thyroid function tests sent. Crit and retic sent.\n\nPneumogram started at .\n\nNo contact from thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-17 00:00:00.000", "description": "Report", "row_id": 1978224, "text": "Neonatology Attending\nDay 18\nCGA 40 1\n\nRA. RR30-60s. BS cl and =. On caffeine. No A&Bs. Pneumogram completed. HR 130-160s. No murmur. BP 68/34, 45.\n\nHct 44.8, r 0.8\n\nWt 2845, up 40 gms. PO ad . Nl voiding and . Tr stool.\nOn trivisol.\n\nIn open crib.\n\nTSH 31\nT4 14.4\nT3 156\nFree T4 2.4\n\nA/P:\nDoing great on caffeine. Pneumogram report pending. Anticipate d/c soon if good report.\n\nWill discuss TFTs with endocrine service.\n\nFollow-up appt with both pedi and endocrine service already arranged.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-05 00:00:00.000", "description": "Report", "row_id": 1978171, "text": "NICU Nursing Progress Note\n\n\nRESP\nO: Remains in nasal cannula 100% requiring range of 13-100cc\nflow to maintain O2 sats within 94-97 parameters. Breath\nsounds, resp rate, and WOB are at baseline. Marked periodic\nbreathing pattern frequently noted on monitor during which\ninfant's stat drift into the low 80's. Also, O2 requirement\nincreases after feeding.\nA: Premature breathing pattern evident.\nP: Monitor and assess. Support adequate ventilation.\n\nHEMODYNAMICS\nO: Cap refill brisk. Mean BP 39. No murmur appreciated.\nPulses wnl.\nA: No evidence of shunting.\nP: Monitor and assess.\n\nHYPERBILI\nO: Infant jaundiced. Remains under triple phototherapy with\neyes covered. Po feeding well and passing large amount of\ngreen stool.\nA: Hyperbili of prematurity.\nP: Check serum bili in a.m.\n\nSEPSIS\nO: Remains on 48 hr rule out course of antibiotics as\nordered. VSS.\nA: No evidence of compromise.\nP: Continue plan of care.\n\nNUTRITION\nO: PIV heparin locked after infant demonstrated ability to\ntake at least 80cc/kg/day of enteral feeds. Infant has done\nwell once at the breast and fairly the next time. Bottle fed\nwell takiing in excess of minimum requirement of BM. Abd\nexam benign. Voiding and passing large amt of green stool.\nA: Feeding well.\nP: Continue to BF with supplement.\n\nDEVELOPMENT\nO: Temp stable on warmer with weaning control point. Active\nand alert with good tone. Variably vigorous for BF. Sucking\non pacifier.\nA: APpropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom and Dad in several times. Updated at length at\nbedside regarding infant's status and plan of care. Mom is\npumping and has obtained an electric pump for home. Many\nconcerns voiced regarding infant's potential for continued\nhospitalization in light of family issues with day care,\nwork, and transportation. Advised parents to expect that\ninfant will be observed and monitored here for a time AFTER\ncoming off cannula. are schedules to return to \nleaving child care and transportation up in the air.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-05 00:00:00.000", "description": "Report", "row_id": 1978172, "text": "Neonatology NP Note\nPE\nAFOf,sutures opposed,\ncomfortable respirations in NCO2, lungs clear/=\nRRR, no murmur, pink and wellperfused\nabdomen soft, nontender and nondistended, active bowel sounds\njaundice,\nactive with good tone\n\nMet with mother at bedside, updated\nObserved infant breastfeeding-appropriate latch on with coordinated sucking and swallowing.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1978216, "text": "Infant CPR Class Note\nO: Both Mom and Dad presented at 1630 for CPR class. They watched video and demonstration of infant CPR and choking maneuvers by this RN. Both practiced CPR and choking maneuvers on manikin. All questions answered. Reviewed \"Back to Sleep\" brochure and safe sleeping. CPR poster and \"Back to Sleep\" brochure given. Class concluded at 1720.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1978217, "text": " ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: cursory exam during feeding by mother\nSkin: warm and dry; colro pink\nanterior fontanel flat; no murmur; + bowel sounds\nalert and active; fixated gaze\n" }, { "category": "Nursing/other", "chartdate": "2159-05-06 00:00:00.000", "description": "Report", "row_id": 1978173, "text": "NURSING PROGRESS NOTE\n\n\n1 - RESP - PT REMAINS AT RA. O2NC 13-50CC, 100%. BSC/=.\nOCC DESAT TO 80S.\n\n2 - FEN - TF=80CC/K BM/E20. PT PO FEEDS, NO SPITS.\nBREAST FEEDING WELL X1. PO FEEDING 30-53CC. ABD SOFT, +BS,\nNO LOOPS. DSTICK=102. PT VOIDING 3CC/K/HR YESTERDAY,\nSTOOLING. WT=2.715(+75)\n\n3 - - PT UNDER TRIPLE PHOTOTHERAPY, EYE SHIELDS\nON. PT JAUNDICE. BILI SENT - PENDING.\n\n4 - SEPSIS - PT CONTINUES ON AMP AND GENT. TEMP STABLE.\nALERT, WAKING FOR CARES.\n\n5 - DEV - TEMP STABLE ON OPEN WARMER. ALERT, WAKING FOR\nCARES. AFOF. MAEW.\n\n6 - PARENT - MOM AND GRANDPARENTS IN, ASKING APPROP\nQUESTIONS. ASSISTING W/ CARES.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-06 00:00:00.000", "description": "Report", "row_id": 1978174, "text": "Neo attending\nDOL 7 for this now 38 week infant.\n\nAdmitted from home for and desaturations. Now in NCO2 25-50 cc's in 100%. Noted to be hypothyroid on newborn screen.\nPlaced on synthroid.\n\nHct 49 on admission. Weight is 2715 up 75 gms (2895=BW)\nOn triple phototherapy; bili this am 11.6/0.5\n\nContinues on Amp/gent for likey 48 hour rule out.\n\n\nRRR no m\nClear BS\nSoft abdomen\n+ 2 pulses\n\nA/P:\n\nTerm infant with resolving hyperbilirubinemia. Change to single. Check bili in AM.\nD/C Amp/Gent.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-06 00:00:00.000", "description": "Report", "row_id": 1978175, "text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in nasal cannula 100% requiring 25-75cc flow to\nmaintain O2 sats above 94. Breath sounds,resp rate, and WOb\nare at baseline. Occasional drifting sats into the mid 80's\nwith feeds and after.\nA: O2 requirement persists.\nP: Support adequate ventilation.\n\nSEPSIS\nO: Remains on ampi and Genta. VSS> Tone wnl. Active.\nA: No evidence of compromise.\nP: D/C antibiotics tonight if 48 hr cultures are neg.\n\n\nO: Slightly jaundiced. Decreased to single overhead\nphototherapy at 1500. Stooling with each diaper change.\nFeeding well.\nA: Resolving .\nP: Check serum bili in a.m.\n\nNUTRITION\nO: Infant BF very well without supplement X2 today. Bottle\nfe with bottle and takingfar in excess of minimum\nrequirement and waking early for some feeds. Voiding and\nstooling.\nA: Much improved feeding.\nP: Continue plan of care.\n\nDEVELOPMENT\nO: Temp stable on warmer with temp off. Active and alert\nwith good tone. Sucking on pacifier.\\\nA: Appropriate behavior.\nP; Support devlopment.\n\nPARENTING\nO: Mom and Dad in for 2 feeds today. Plan to return this\nevening for 2100. Mom handles infant well. Updated regarding\ninfant's status and plan of care.\nA: Invovled parents.\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-16 00:00:00.000", "description": "Report", "row_id": 1978218, "text": "PCA Note\n\n\nRESP: Infant remains in RA; O2 sat 95-100%. RR 30-60's.\nLS cl/= bilat. Infant is breathing comfortably with no\nincreased WOB. No spells, no desats this shift. Infant\nremains on caffeine. Repeat pneumogram to be started in\nthe evening. Continue with current regimen and assess\nrespiratory status.\n\nFEN: BW 2895. Weight tonight 2805; up 35g. Infant is on\nan adlib/demand schedule. TF 80cc/k/d of BM24 with\nenfamil powder. Infant has been bottling 100cc Q4. 24hr\nintake= 119cc/k. Abd. benign. Infant is voiding and\n; heme trace positive x2. Anal fissures noted;\ndesitin applied with each diaper change. No spits.\nTrivisol to be started. Continue to encourage PO's.\n\nDEV: Infant is swaddled in OAC. Temps stable. Alert and\nactive with cares. Waking Q4. Enjoys pacifier. Continue to\nsupport developmental needs.\n\n: No known contact thus far. Continue to support\nand update as needed.\n\nENDOCRINE: Infant remains on synthroid fro thyroid\ndeficiency. He is stable. Repeat prior to d/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-16 00:00:00.000", "description": "Report", "row_id": 1978219, "text": "NPNOte\nInfant alert, active, trace of Jaundice still present,easy resp effort, no spells, no desats, sats >93%,mom called for a update,mom will be in for 8am care. Po fed well and tolerated.On Syntroid,I agree with above note by PCA Tran.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-16 00:00:00.000", "description": "Report", "row_id": 1978220, "text": "Neonatology Attending Note\nDay 17\nCGA 40\n\nRA. RR30-60s. BS cl and =. Caffeine. Repeat pneumogram tonight. HR 120-160s. No murmur. No A&Bs or desats. BP 64/32, 43.\n\nWt 2805, up 35. PO ad (TFI: 119 + BF).\n\nSynthroid.\n\nIn open crib.\n\nA/P:\n-- pneumogram tonight\n-- TFTs in am, Hct and retic in am\n-- repeat hearing screen\n-- car seat screening\n-- anticipate discharge planning in Fri.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1978214, "text": "Neonatology Attending Note\nDay 16\n\nRA since yesterday. Clear and = BS. No murmur. HR 140-160s.\n\nWt 2770, down 5 gms. PO ad . TFI: 90 + BFing.\n\nOn synthroid.\n\nIn open crib.\n\nA/P:\n-- cont to monitor on caffeine, repeat pneumogram Thurs eve.\n-- cont to follow weights\n-- check hct, retic and TFTs prior to going home\n-- updated both family and pediatrician\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1978215, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~40-50's, no increase work of breathing noted. LS clear/=.\nNo A&B's noted this shift. He remains on Caffeine. A: Pt.\nis stable in RA. P: Continue to monitor respiratory\nstatus. Monitor for A&B's. Plan for repeat pneumogram to\nstart Wednesday evening.\n\n#2. FEN O: Pt. is ad 80cc/kg/d of BM24w/ Enf.\npowder or E24 =39cc Q 4hrs. He is breastfeeding very well,\n~Q4hrs for +20min. Abdomen is soft, pink, +bs, no\nloops/spits noted. He is voiding/ QS. A: Pt. is\ntolerateing current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance.\n\n#5. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. He is alert and active w/ cares,\nsleeps well in between. Fonatnelle soft/flat. He wakes\nindependently for cares. A: AGA P: Continue to provide\nenvironment appropriate for growth and development.\n\n#6. O: Mom in for cares and remains here\nthroughout the shift. She was updated at bedside on pt's\ncurrent status and daily plan of care. Mom is active and\nindependent in cares, asking approprite questions. A:\nFamily is loving and involved. P: Continue to update,\nsupport and edcuate. Continue w/ discharge\nteaching/planning. Apnea monitor will be delivered and\ntaught w/ mom and dad on Thursday am. is set up to\nvisit on Saturday am in the event that this infant is ready\nfor discharge on Friday.\n\n#7. Endocrine O: Pt. remains on Synthroid. A: stable\nP: Plan to check TFT's prior to D/C.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-14 00:00:00.000", "description": "Report", "row_id": 1978209, "text": "Neonatology Attending Note\nDay 15\n\nNC 13cc/100%. RR30-40s. Cl and = BS. No desats/bradys. On caffeine. No murmur. HR 120-150s. Pink, sl jaundiced.\n\nWt 2775, up 10 gms. 80 cc/k/day PE/BM24. well. Nl voiding and .\n\nOn synthroid.\n\nIn open crib.\n\nA/P:\n-- Pneumogram over the weekend c/w immature respiratory pattern and on Saturday started caffeine. Resp pattern and O2 seems improved. Repeat pneumogram Thurs. Discharge planning on home monitor.\n-- Weds check TFTs\n" }, { "category": "Nursing/other", "chartdate": "2159-05-14 00:00:00.000", "description": "Report", "row_id": 1978210, "text": "0700-1900 NPN\n\n\nRESP: Infant received in nasal cannula, fiO2=100%, 13cc\nflow. Infant currently in RA, with O2 sats=94-100% (off NC\nsince 1500). Breath sounds clear and equal bilaterally, no\nretractions noted. RR=20-60's. No desats, no bradys so far\nthis shift. Continues on caffeine. Continue to monitor resp\nstatus.\n\nFEN: Ad with a of 80cc/kg/d of BM24/PE24, all PO.\nInfant BF x 3 so far this shift (please see flowsheet for\ndetails). Infant waking q2-5hr for feeds. Abdomen pink,\nsoft, round, +BS, no loops. No spits. Voiding and \n(guiac negative). Continue to monitor FEN status.\n\nDEV: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well in between cares. Brings hands to face,\nsucks on pacifier for comfort. MAE. Continue to support G+D.\n\n: Mom here for all cares, involved, independent, and\nloving. Updated on patient's current status by this RN and\n. Continue to support and educate family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-14 00:00:00.000", "description": "Report", "row_id": 1978211, "text": "0700-1900 NPN\nEndocrine: Infant continues on Synthroid. Continue to monitor infant.\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1978212, "text": "NURSING PROGRESS NOTE\n\n\n1 - RESP - PT RECEIVED AT RA. BSC/=. O0CC DESATS TO HIGH\n80S - QSR. NO A/BS NOTED, ON CAFFEINE\n\n2 - FEN - TF= 80CC/K OF BM24/E24. PT ALL PO FEEDS,\nNO SPITS. TAKING IN 92CC/K AND BREAST FEEDING ALL THROUGH\nDAY YESTERDAY. ABD SOFT, +BS. PT VOIDING, ,\nGUIAC-. WT=2.770(-5)\n\n5 - DEV - TEMP STABLE IN OPEN CRIB. SWADDLED. ALERT,\nWAKING FOR CARES. SUCKING ON PACIFIER. AFOF\n\n6 - PARENT - NO FAMILY CONTACT THUS FAR TONIGHT\n\n7 - ENDOCRINE - PT REMAINS ON SYNTHROID AND LEVELS TO BE\nDRAWN AT END OF WEEK\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1978213, "text": " Nurse Case Manager\nA referral was made to Denmarks Home Medical (phone , Denmarks rep. cell phone ) for a home apnea monitor. The settings for the monitor are a high heart rate of 230 BPM and a low heart rate of 80 BPM with a 20 second apnea delay. This will be a memory monitor. Please attach to the medical chart a prescription for the apnea monitor with indication of these settings and the Denmarks rep will pick this up when she comes to the NICU. Stick on leads were ordered due to the infant's small size, not a wrap around lead. The mother is aware of the above referral and is in agreement with the plan of care. The Denmarks rep will call the mother at the hospital today to arrange an appointment to teach both the use of the monitor prior to discharge. As indicated in the medical note on , a referral has been made to the for follow up skilled nursing visits after discharge home. If you have any questions, please page me at beeper .\n" } ]

[ { "category": "Radiology", "chartdate": "2165-10-28 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 980821, "text": " 10:18 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: evidence of DVT in lower ext?\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman post op with bilateral leg tenderness and edema\n REASON FOR THIS EXAMINATION:\n evidence of DVT in lower ext?\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 84-year-old woman postop with bilateral leg tenderness.\n\n REASON FOR EXAM: Question DVT in lower extremities.\n\n There were no previous ultrasound exams used for comparison.\n\n FINDINGS: -scale and Doppler son of bilateral common femoral,\n superficial femoral, and popliteal veins were performed. There is normal\n compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980180, "text": " 3:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, fluid overload\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman hospitalized with abd pain and pelvic mass, now with\n shortness of breath; has hx CAD s/p CABG\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n INDICATION: Shortness of breath.\n\n Cardiac silhouette is upper limits of normal in size for portable technique.\n Bibasilar patchy retrocardiac opacities are present, likely atelectasis, but\n aspiration is an additional consideration in the appropriate clinical setting.\n Right hemidiaphragm is moderately elevated. Vascular calcifications are seen\n in the region of both carotid arteries.\n\n" }, { "category": "Radiology", "chartdate": "2165-10-23 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 980216, "text": " 6:36 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT PELVIS W/CONTRAST Clip # \n CT ABDOMEN W/CONTRAST\n Reason: evaluate pelvic mass; ?bowel obstruction; evaluate for pulmo\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with new pelvic mass dx'd after presentation with abd pain,\n N/V; now with tachypnea and fever, ?infiltrate on CXR; clinical suspicion for\n PE low\n REASON FOR THIS EXAMINATION:\n evaluate pelvic mass; ?bowel obstruction; evaluate for pulmonary process,\n ?metastasis, ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT torso.\n\n INDICATION: 84-year-old female with new pelvic mass diagnosed at a\n presentation with abdominal pain at an outside hospital. Patient is\n presenting with tachypnea, fever, nausea and vomiting. Assess for bowel\n obstruction and/or metastasis. Assess for pulmonary embolism.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast MDCT axial images of the chest were acquired.\n Following administration of intravenous contrast, MDCT axial images were\n acquired of the chest. Oblique, sagittal and coronal reconstructed images\n were then obtained. Following administration of intravenous and oral\n contrast, MDCT axial images were acquired from the lung bases to the pubic\n symphysis. Coronal and sagittal reformatted images were then obtained.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no filling defects\n present within the pulmonary arterial vasculature. The pulmonary artery is\n normal in size. Extensive calcifications of the left anterior descending,\n left circumflex, and right coronary arteries are noted. There is no\n pericardial effusion. A few, non-pathologically enlarged mediastinal and\n prevascular lymph nodes are noted. No hilar or axillary pathologic\n lymphadenopathy is present. An ill-defined patchy opacity is noted within the\n right upper lobe measuring 6 mm in diameter (4:69). No other pulmonary\n nodules or masses are noted. There is bibasilar atelectasis, right greater\n than left. A more patchy area of consolidation at the right lung base most\n likely represents atelectasis. Diffuse, patchy ground-glass appearance of the\n lungs bilaterally is probably related to the respiratory phase of the patient.\n Incidental note is made of a large hiatal hernia.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: A 2.4 cm x 2.1 cm low-attenuation lesion\n is present within segment of the liver and its appearance is most\n consistent with a simple cyst (10:15). No focal liver lesions are identified.\n Mild intrahepatic biliary dilatation is noted. A small gallstone is present\n within the gallbladder which is overall not distended or inflamed in\n appearance. The common bile duct is mildly prominent but there is no evidence\n of obstruction. There is mild fatty replacement of the pancreas. The spleen,\n (Over)\n\n 6:36 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT PELVIS W/CONTRAST Clip # \n CT ABDOMEN W/CONTRAST\n Reason: evaluate pelvic mass; ?bowel obstruction; evaluate for pulmo\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n stomach, adrenal glands, and abdominal portions of the large and small bowel\n are unremarkable. There is passage of oral contrast through to the bowel and\n there is no evidence of obstruction.\n\n There is a large low-attenuation lesion of the medial aspect of the left\n kidney measuring 3.4 x 4.0 cm, which represents either a simple cyst versus a\n parapelvic cyst. Multiple other low-attenuation lesions, some exophytic, of\n the left kidney too small to characterize but most likely represent simple\n cysts. Similarly, several low-attenuation areas within the right kidney most\n likely also represent simple renal cysts but are too small to characterize.\n\n A mildly enhancing right diaphragmatic lymph node measuring 1.4 x 0.9 cm is\n noted (10:16). Scattered retroperitoneal and mesenteric lymph nodes are also\n present but none meet criteria for pathology by CT.\n\n\n CT OF THE PELVIS WITH IV CONTRAST: A Foley balloon is present within a\n decompressed bladder which is difficult to visualize. No discernable uterus\n or ovaries are identified within the pelvis. The pelvis itself is dominated\n by a large, fluid-density, complex, cystic mass measuring 28.4 x 16.1 x 23.2\n cm (10:59, 13:23). This mass appears to arise from the deep pelvis and is\n intimately associated with the broad ligament and possible remnants of the\n adnexal structures. The wall of this mass is markedly thickened and mildly\n enhances.\n\n There are numerous diverticula of the sigmoid colon. Just posterior to this\n mass there is a small segment of sigmoid colon which appears to have a mildly\n thickened wall with adjacent fat stranding. There is no intraluminal contrast\n at this level which somewhat limits detailed evaluation. A small amount of\n pelvic fluid is also noted. No pathologically enlarged inguinal or pelvic\n lymph nodes are noted.\n\n OSSEOUS STRUCTURES: No suspicious lytic or blastic lesions are identified. A\n heterogeneous, predominantly low-attenuation lesion within the T10 vertebral\n body is most consistent in appearance with a hemangioma. Mild anterior\n wedging of the L1 vertebral body is also noted.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n 1. Large, 20-cm complex, cystic pelvic mass with features highly worrisome\n for neoplasm. Differential diagnosis would include such entities as ovarian\n cystadenocarcinoma. No uterus or ovaries are specifically identified.\n Clinical correlation with surgical history is recommended. Other etiologies\n (Over)\n\n 6:36 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT PELVIS W/CONTRAST Clip # \n CT ABDOMEN W/CONTRAST\n Reason: evaluate pelvic mass; ?bowel obstruction; evaluate for pulmo\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n such as a benign, post-surgical peritoneal inclusion cyst are also possible,\n but considered less likely. A least one, enlarged, mildly enhancing lymph\n node is noted. No evidence of peritoneal carcinomatosis.\n\n 3. There is extensive sigmoid diverticulosis. Mild thickening of a small\n segment of the sigmoid colon just inferior and posterior to the large cystic\n mass could represent a focal area of diverticulitis. This area is\n incompletely characterized secondary to lack of intraluminal oral contrast.\n Clinical correlation is recommended. There is no evidence of bowel\n obstruction.\n\n 4. Bibasilar atelectasis, right greater than left. No focal areas of\n consolidation is identified. A 6-mm, rounded focus in the right upper lobe of\n the lung could represent a focal area of atelectasis or represent a focal\n nodule. Attention to this area should be paid on subsequent examinations.\n\n 5. Mild anterior wedging of the L1 vertebral body could represent a\n compression fracture of indeterminate chronicity. Clinical correlation is\n recommended.\n\n 6. Cholelithiasis without evidence of cholecystitis.\n\n 7. Bilateral renal low attenuation lesions, most too small to characterize\n but most likely simple cysts.\n\n Findings were discussed over the telephone with Dr. by Dr. . Sun on\n the evening of .\n\n" }, { "category": "Radiology", "chartdate": "2165-10-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 980959, "text": " 8:55 AM\n CHEST (PA & LAT) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman post operative with concern for aspiration pneumonia during\n surgery at intubation.\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old female with post-operative concern for aspiration.\n\n COMPARISON: Radiographs .\n\n TWO VIEWS OF THE CHEST: Small bilateral pleural effusions obscure the\n costophrenic angles, left greater than right. A left basilar vague opacity is\n present likely seconday to the underlying effusion and/or atelectasis. The\n lungs are otherwise clear. There is left ventricular enlargement. The bony\n thorax is normal.\n\n" }, { "category": "Radiology", "chartdate": "2165-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980523, "text": " 4:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of aspiration?\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman immediately post op with emesis during intubation. Tube in\n place and inflated when emesis occurred.\n REASON FOR THIS EXAMINATION:\n evidence of aspiration?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative with emesis during intubation and possible aspiration\n pneumonia.\n\n FINDINGS: Comparison with the study of , the pulmonary vasculature is\n more prominent, though some of this may nearly reflect relative\n of the image. Nevertheless, there probably is some\n increasing pulmonary venous pressure or overhydration. The left hemidiaphragm\n is not sharply seen and the possibility of atelectasis or developing\n aspiration pneumonia in the retrocardiac region must be considered.\n\n Endotracheal tube tip lies about 3 cm above the carina. The nasogastric tube\n extends only to the lower esophagus. This information has been telephoned to\n Dr. , who is taking care of the patient.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2165-10-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 980268, "text": " 7:38 AM\n CHEST (PA & LAT) Clip # \n Reason: Now on better study (non portable), evidence of atelectasis,\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with large abdominal mass and desaturation. CT scan showed\n no PE. Portable CXR yesterday revealed ?atelectasis ?infiltrate\n REASON FOR THIS EXAMINATION:\n Now on better study (non portable), evidence of atelectasis, or\n infiltrate/aspiration?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Questionable atelectasis.\n\n PA and lateral upright chest radiograph compared to , and CT\n torso from .\n\n The heart size is moderately enlarged but stable. The hiatal hernia is\n demonstrated on PA view. The cardiomediastinal silhouette is unremarkable.\n The lungs are clear except for right lower lobe consolidation seen on both PA\n and lateral view accompanied by pleural effusion and corresponding to right\n lower lobe atelectasis seen on the .\n\n\n" }, { "category": "Radiology", "chartdate": "2165-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980589, "text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: OVARIAN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 F s/p resection of torsed ovary, re-intubated in the PACU for tachypnea\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tachypnea.\n\n Single portable radiograph of the chest is submitted. The left lateral\n hemithorax is excluded. When compared with the nasogastric tube has\n been advanced into the stomach. Endotracheal tube is present with its tip at\n the clavicular heads. No right-sided effusion. No pneumothorax is seen. No\n consolidation is identified.\n\n IMPRESSION:\n\n Interval repositioning of the nasogastric tube. NGT tip is now present within\n the stomach.\n\n\n" }, { "category": "Echo", "chartdate": "2165-10-24 00:00:00.000", "description": "Report", "row_id": 86250, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for Congestive heart failure/Preoperative assessment. (Hx of CABG now with Large pelvic mass and Le edema to thighs).\nHeight: (in) 62\nWeight (lb): 160\nBSA (m2): 1.74 m2\nBP (mm Hg): 108/50\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 15:21\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Hyperdynamic\nLVEF >75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Mildly dilated aortic arch. Focal calcifications in aortic\narch. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No valvular AS. The\nincreased transaortic velocity is related to high cardiac output. Mild (1+)\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Moderate to severe [3+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Left ventricular systolic\nfunction is hyperdynamic (EF 70-80%). There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The aortic\narch is mildly dilated. There are focal calcifications in the aortic arch. The\naortic valve leaflets (3) are mildly thickened and display slightly reduced\nsystolic excursion. There is no valvular aortic stenosis. The increased\ntransaortic velocity is likely related to high stroke volume. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. The supporting\nstructures of the tricuspid valve are thickened/fibrotic. Moderate to severe\n[3+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-10-26 00:00:00.000", "description": "Report", "row_id": 1632600, "text": "Resp Care\n\nReadyness for extubation is being monitored on this pt. She has already been extubated once in PACU and was dyspneic, requiring re-intiubation. There are some cardiac issues involved, including mitral regurg and she may require some dieretics. Two RSBIs were done this shift, both demonstrating a tendancy towards tachypnea and numerical values of 120 +. She remains intubated for the time being and on propofol.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-26 00:00:00.000", "description": "Report", "row_id": 1632601, "text": "Respiratory Care\npt was extubated today at 1200. Post extubation vitals were HR 89, BP 147/68, RR 22 and non-labored, SpO2 99% on 0.5 via OFM. Pt has a good cough and is able to speak. Pt has clear lung sounds and no stridor was noted. Care plan is to contine to follow and wean FiO2 as tol. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-26 00:00:00.000", "description": "Report", "row_id": 1632602, "text": "NPN\n\nNeuro: Pt was extubated early this afternoon, she is now off of the propofol gtt, alert and orientedx3, out of bed to the chair and was able to take a few steps.\n\nCV: Conts on IV lopressor since she remains NPO, her BP has been 110s-140s, HR 70s-80s, her aline was removed.\n\nResp: Extubated today, now on 3 liters NC and sating in the mid 90s. She was coughing up thick yellow sputum - sent for gram stain and clx, her temp has decreased to the 99 range but she was started on IV abx for ? pneumonia. She is using the incentivespirometer and is fairly proficient at it.\n\nGI: Remains NPO, the NG is still in place, she has a very small amount of dark bilious fluid which is OB pos, she conts on IV protonix. Her ABD is soft, pos bowel sounds, no stool. She has minimal abd pain when still () but this increases to with exertion, she has been given .5 mg of IV dilaudid which brings her pain down to 1. Her dressing is dry and intact, no drainage.\n\nGU: Her U/O has been 20-7055/hr, she is now on NS at 100cc/hr.\n\nSoc: She has had numerous family members in today.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-27 00:00:00.000", "description": "Report", "row_id": 1632603, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nPT. HAD UNEVENTFUL NIGHT. SLEPT MOST OF SHIFT. AFEBRILE. MEDICATED X1 FOR ABDOMINAL INCISION PAIN WITH COUGHING WITH GOOD EFFECT.\n\nNEURO: PT. A+OX3. MAE. MEDICATED AS ABOVE.\n\nRESP: PT. ON 3L NASAL CANNULA WITH SATS >95%. BREATH SOUNDS CTA. NO C/O SOB. PT. DOES HAVE PRODUCTIVE COUGH. SPUTUM YELLOW TINGED. REMAINS ON ANTIBIOTIC THERAPY FOR PROBABLE PNEUMONIA.\n\nCV: PT. NSR. NO ECTOPY. BP WNL. IV METOPROLOL HELD AS SBP LOW 100'S. + PULSES. GENERALIZED EDEMA. AFEBRILE.\n\nGI: PT. TOLERATING ICE CHIPS. ? ADAT THIS AM. ABD. SOFT. BS+. NO BM. ABD. INCISION SITE DRESSING C+D+I. NGT REMAINS IN PLACE. SMALL AMOUNTS OF DARK GREEN BILIOUS SECRETIONS WHEN ATTACHED TO SUCTION.\n\nGU: FOLEY CATH IN PLACE DRAINING CLEAR YELLOW OUTPUT. UP APPROX. 20-40CC/HR. MD'S AWARE.\n\nSKIN: INTACT\n\nACCESS: 2 PIVS\n\nPLAN: ? ADVANCE DIET TODAY. ? REMOVE NGT. CONTINUE WITH PAIN MEDS PRN. ? C/O TO FLOOR. PT.'S DAUGHTER CALLED AND UPDATED ON PT.'S CONDITION / POC. WILL BE IN THIS AM TO VISIT. AM LABS PENDING. FULL CODE\n" }, { "category": "Nursing/other", "chartdate": "2165-10-26 00:00:00.000", "description": "Report", "row_id": 1632599, "text": "NPN 7P-7A\nTHIS IS AN 84YO FEMALE WITH CAD, S/P CABG, HTN, HCHOL, GERD AND RA WITH ACUTE N/V AND RECENT DX'D PELVIC MASS. TO OR TODAY WHERE 4.8L CLEAR FLUID WAS ASPIRATED FROM BENIGN CYST (LIKELY TORSED OVARY). ALSO HAD PERITONITIS FROM TORSION. WAS EXTUBATED POST-OP, HOWEVER, REINTUBATED FOR TACHYPNEA AND SHALLOW BREATHING. TRANSFERRED HERE TO MSICU FOR OVERNIGHT VENT MANAGEMENT AND PROBABLE EXTUBATION IN AM.\n\nNEURO: PT. SEDATED ON PROPOFOL AT 35MCG/KG/MIN. OPENS EYES TO STIMULI. NODS HEAD YES AND NO TO QUESTIONS ASKED. BILAT WRISTS RESTRAINED FOR TUBE PROTECTION. PUPILS EQUAL AND REACTIVE. NO S+S OF PAIN.\n\nRESP: INTUBATED: AC-50%/600/5/12. BREATH SOUNDS CTA. MINIMAL SECRETIONS WITH SUCTIONING.\n\nCV: PT. NSR. NO ECTOPY NOTED. SBP 120'S TO 140'S. L RADIAL ALINE PLACED IN OR WITH SHARP WAVEFORM. + PULSES. NO EDEMA. SPIKED TEMP TO 101 AT MIDNIGHT. BLOOD CULTURES SENT. AWAITING RESULTS.\n\nGI: PT. NPO. ABD. SOFT. BS HYPOACTIVE. INCISION SITE DRESSING C+D+I. NO BM THIS SHIFT.\n\nGU: FOLEY IN PLACE WITH GOOD UO. CLEAR YELLOW URINE\n\nSKIN: INTACT\n\nACCESS: R EJ\n 2 PIVS\n\nPLAN: GOAL IS TO EXTUBATE PT. THIS AM. WILL DO RSBI. CONTINUE WITH CURRENT POC. MONITOR RESP/CV STATUS. AM LABS PENDING. PT.'S FAMILY IN LAST NIGHT. UPDATED ON CONDITION AND POC. VERY SUPPORTIVE FAMILY. FULL CODE.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2103-05-16 00:00:00.000", "description": "Report", "row_id": 1659453, "text": "Nursing Progress Note (2200-0700)\n64 y.o. female,w/pud, chron's. CAD s/p RCA stent ', CHF, RF, HTN, Dm, recent MICU admission for hypotension and RF. Admitted from clinic while at f/u with CR. 3.8, general malaise/CP/right knee pain. Found to have T- 102.3, with right knee fluid pos. WBC's. pan-cultured and abd. CT; given vanco, zosyn, flagyl. Became hypotensive, started on levophed, after given 4500 fluid, sent to CCU as MICU border for further management.\n\nS:\" It just hurts all over!\"\n\nO:Please see careview for all objective data.\n\nA:\nNeuro: Pt. alert and oriented x 3, but appears forgetful. Somnolent but arouses to voice and able to answer direct questions, elaborates only with encouragement.\n\nCV: HR: 89-95 in NSR, no ectopy. Arrived on levophed at 0.044mcg/kg/min; weaned off by 2 am. Maintaining MAP's 65 with SBP 101-119. CVP 7-9. NS infusing at 250 ml/hr with 1 liter bolus given between 130 and 330 am. Denies current c/o CP. Trace LE edema, pos. csm, pedal pulses palpable. Two sets CE's obtained; awaiting 3rd set with am labs. K+ 5.2 (down from 7 in ED). Likely need TTE.\n\nResp: LS clear/diminished throughout. Denies c/o SOB or DOE. O2 sats 100% on 2 l via NC.\n\nID: Tmax 99.3 (102.3) Had bc's, urine, cxray in ED; also had right knee tapped; fluid results with WBC's; awaiting OR for washout and ?revision (s/p Rt knee replacement in w/ revision in ).team to check TTE given likely staph infection. Started on Vanco and Zosyn. Vanco trough sent with am labs.\n\nGI: Abdomen softly obese, nt, nd, active bsx4. denies abdominal pain.no bm this shift.\n\nGU: foley patent draining large volumes clear, yellow urine. CR 2.6 (3.8).\n\nENDO: DM, given 68 units glargine at midnoc for BG 141.\n\nSKIN/MSKLT: Endorses right knee and right arm pain. Right knee tapped in ED for fluid sample; bandaid over site. No warmth or swelling noted to knee, but bil. LE's appear soft without much tone. pt. reports ambulates with cane at baseline. although endorses pain, denied offer of medication and slept overnight appearing comfortable.\n\nACCESS: Right subclavian 3 lumen.\n\nP:Continue to monitor tele and vs. Monitor I and O and daily weights. Monitor CVP (target ). Monitor for c/o pain/discomfort. Await TEE. Follow labs;cr., pending bc's, urine culture/tox. screen. monitor somnolence; potential head CT if no improvement.Likely awaiting washout in OR of right knee. Await further team plans.\n" }, { "category": "Nursing/other", "chartdate": "2103-05-16 00:00:00.000", "description": "Report", "row_id": 1659454, "text": "ICU Progress Note:\n\nS- \"I'm hungry and want to eat!\"\n\nO- see flowsheet for all objective data.\n\nNeuro- upset about in hospital and again having problems with her R leg- moving all extremitites, but unable to raise arms up high- states has pain in shoulders- c/o R knee pain w/ movement- states muscles feel weak & everything hurts- cooperative- follows command- PERL.\n\nID- WBC 12.3 (was 13.4)- T max 99.4 Po- vanco level this am 27.7- last vanco dose given @ 12am- con't on zosyn 2.25g IV q6hrs- seen by ortho team- placed on OR schedule for washout I&D R knee- surgical consent signed- seen by anesthesia- anesthesia consent signed- pre-op checklist completed- awaiting transfer to OR.\n\nResp- In O2 2l via NC- lung sounds diminished @ bases, otherwise clear- resp even, non-labored- SpO2 99-100%.\n\nCV- Tele: ST no ectopy- HR 103-109- NIBP 100-128/54-62 MAPs 63-76 off pressor- Hct 27.0- K 5.6- CPK's trending down- no cardiac complaints offered.\n\nGI- abd obese, soft, non-tender- (+) bowel sounds- NPO- 1 large tan colored soft formed stool today- quiac (-) glucose range 115-130- no insulin given today per sliding scale.\n\nGU- foley draining clear yellow colored urine qs- BUN 27 Crea 2.2 trending down.\n\nIV access- R subclavian TLCL.\n\nA- Pre-op for I&D (washout) R knee\n\n Transfer to OR when called- plan is to do I&D and TEE- Once recovered from anesthesia & if stable, plan is to have MRI cervical spine.\n\n" }, { "category": "Nursing/other", "chartdate": "2103-05-16 00:00:00.000", "description": "Report", "row_id": 1659455, "text": "Addendum: I&D of R knee cancelled for today- NPO after 12am for more extensive surgery tomorrow, if OR time available (otherwise, Friday)- Mg 1.6 this am- Mg sulfate 2g IV given- repeat K pending- Pt called out to medical floor- awaiting room assignment.\n" }, { "category": "Nursing/other", "chartdate": "2103-05-16 00:00:00.000", "description": "Report", "row_id": 1659456, "text": "Addendum: 7 rings removed from fingers and a pair of gold hoop earings removed pre-op and placed in bag- jewelry given to son to bring home @ 1800 per patient request.\n" }, { "category": "Echo", "chartdate": "2103-05-16 00:00:00.000", "description": "Report", "row_id": 103377, "text": "PATIENT/TEST INFORMATION:\nIndication: ? Endocarditis.\nHeight: (in) 62\nWeight (lb): 205\nBSA (m2): 1.93 m2\nBP (mm Hg): 115/52\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 09:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or\nvegetations on mitral valve, but cannot be fully excluded due to suboptimal\nimage quality. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis.\nNo masses or vegetations are seen on the aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. No masses or vegetations are seen on the mitral valve, but cannot be\nfully excluded due to suboptimal image quality. Trivial mitral regurgitation\nis seen. The pulmonary artery systolic pressure could not be determined. There\nis no pericardial effusion.\n\nIMPRESSION: No vegetation or abscess seen. Normal regional and global\nbiventricular systolic function. Trace aortic and mitral regurgitation.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis. However, there is no significant valvular\nregurgitation, making endocarditis unlikely.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n" }, { "category": "ECG", "chartdate": "2103-05-21 00:00:00.000", "description": "Report", "row_id": 311493, "text": "Sinus tachycardia. Old inferior myocardial infarction. Poor R wave\nprogression across the anterior precordial leads. Consider prior anteroseptal\nmyocardial infarction. Compared to the previous tracing of poor R wave\nprogression is seen across the precordial leads and the other findings are\nsimilar.\n\n" }, { "category": "ECG", "chartdate": "2103-05-20 00:00:00.000", "description": "Report", "row_id": 311494, "text": "Sinus tachycardia\nConsider prior inferior myocardial infarction although is nondiagnostic and\nbaseline artifact in inferior leads makes assessment difficult\nModest nonspecific ST-T wave changes\nSince previous tracing of , sinus tachycardia rate faster, and modest\nST-T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2103-05-15 00:00:00.000", "description": "Report", "row_id": 311495, "text": "Sinus rhythm at upper limits of normal rate. Lead aVF is nearly isoelectric\nand a Q wave at times appears to be present of uncertain significance. Since\nthe previous tracing of probably no significant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2190-05-06 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1011463, "text": " 8:16 PM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: eval carotid, basilar skull fx through carotid canal\n Field of view: 25 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n eval carotid, basilar skull fx through carotid canal\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:18 PM\n No carotid injury.\n\n Left skull base fracture enters left temporal bone just below mastoid,\n with occipito-temporal suture diastasis. Fx extends longitudinally through\n temporal bone, avoiding middle ear and ossicles, extends through petrous apex,\n into left sphenoid air cells.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Skull base fracture, evaluate for carotid injury.\n\n COMPARISON: Head CT performed two hours prior.\n\n TECHNIQUE: Multidetector helical scanning of the head and neck was performed\n following the administration of IV Optiray contrast. Volume rendered,\n rotational, and curved reformats were displayed as well as coronal, sagittal\n and axial MIPs.\n\n CTA OF THE HEAD AND NECK: There is no evidence of carotid artery injury. The\n carotid and vertebral arteries are seen from their origin through the cervical\n course. The cervical and intracranial branches of the vertebrobasilar system\n and internal carotid arteries are patent with no evidence of stenosis,\n aneurysm, dissection or injury. There is no contrast extravasation. The\n carotid artery appears unremarkable as it passes through the carotid canal in\n close proximity to the subtle temporal bone fracture described on multiple\n prior exams. Again seen is a small stable 5-mm right subdural hematoma,\n hemorrhagic contusion within the right gyrus rectus, and barely visible small\n foci of subarachnoid hemorrhage. The intracranial vessels are unremarkable.\n Visualized lung apices also demonstrate no evidence of pneumothorax. Again\n noted is opacification of the left sphenoid sinus and left mastoid air cells\n from the temporal bone fracture as well as less extensive opacification within\n the maxillary sinuses and ethmoid air cells.\n\n IMPRESSION: No evidence of carotid artery injury. For further description of\n the skull base fracture please see concurrent CT of the temporal bones.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-05-06 00:00:00.000", "description": "CT ORBITS, SELLA & IAC W/ CONTRAST", "row_id": 1011468, "text": " 9:04 PM\n CT ORBITS, SELLA & IAC W/ CONTRAST Clip # \n Reason: EVAL BASILAR SKULL FX THROUGH CAROTID CANAL\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left temporal bone fracture.\n\n COMPARISON: Non-contrast head CT performed two hours prior.\n\n FINDINGS: Limited examination of the brain parenchyma demonstrates no\n significant change compared to two hours prior. Again seen is a 5-mm right\n frontal convexity subdural hemorrhage, hemorrhagic contusion within the right\n gyrus rectus, and a moderate but decreased amount of subarachnoid hemorrhage\n layering along the basal sulci. 4 mm of leftward subfalcine herniation is\n unchanged. Moderate scalp contusion over the left parietal bone is unchanged.\n\n Dedicated views of the temporal bones demonstrate again diastasis of the left\n occipital mastoid suture with a longitudinally oriented fracture extending\n through the temporal bone and petrous apex and into the sphenoid sinus where\n there is a moderate amount of blood. A tiny focus of air is again seen in the\n carotid canal. These findings are actually better seen on thin slices from\n the non-contrast head CT performed two hours prior. A small amount of fluid\n is seen within the left mastoid air cells. The ossicles and inner ear\n structures are intact. There is no hemotympanum.\n\n The right temporal bone is unremarkable, with no evidence of fracture. The\n right mastoid air cells are normally pneumatized and aerated. The right\n internal auditory canal is unremarkable and the ossicles are intact.\n\n Fluid is seen within the sphenoid sinuses and maxillary sinuses.\n\n IMPRESSION: Redemonstration of the left skull base fracture extending from a\n diastasis of the left occipital mastoid suture and through the left temporal\n bone, petrous apex and terminating in the sphenoid sinus. Again, there is\n concern for injury to the carotid canal which has a small focus of air. Please\n see concurrent CTA of the neck to evaluate for carotid injury.\n\n" }, { "category": "Radiology", "chartdate": "2190-05-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1012097, "text": " 11:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for increased bleed or shift.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old man with h/o skull fracture, subdural hematoma and subarachnoid\n blood.\n REASON FOR THIS EXAMINATION:\n please evaluate for increased bleed or shift.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Skull fracture, subdural hematoma and subarachnoid blood.\n Evaluate for change.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: There has been no significant interval change. Small\n right subdural hematoma overlying the right frontal convexity measuring 5 mm\n in thickness is stable. Right frontal gyrus rectus hemorrhage and surrounding\n edema is also unchanged in size and appearance. Blood products within the\n left sphenoid sinus are unchanged. Previously seen subarachnoid blood is no\n longer apparent. Small left posterior parietal scalp hematoma is stable. The\n known skull base fracture is not well demonstrated on this study, performed\n without thin bone reconstructions.\n\n IMPRESSION: No significant interval change since . Stable right\n frontal intraparenchymal and subdural hemorrhages with no new hemorrhage or\n mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2190-05-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1011484, "text": " 12:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Follow up for increase in blood components;Please do at 11pm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old man with right side subdural, IPH and SAH\n REASON FOR THIS EXAMINATION:\n Follow up for increase in blood components;Please do at 11pm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with trauma.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Comparison was made with the previous study of .\n\n FINDINGS: There is a right inferior frontal lobe hemorrhagic contusion\n identified. A small subdural hematoma is seen along the right cerebral\n convexity from frontal to parietal region with blood along the tentorium.\n These findings are not significantly changed since the previous study.\n However, since the previous study the mass effect on the lateral ventricles\n has decreased and there is better visualization of the basal cisterns and\n perimesencephalic cistern noted. There is no hydrocephalus identified. The\n patient has multiple fractures which have been described on the previous\n study.\n\n IMPRESSION: Since the previous study right frontal hemorrhagic contusion and\n right-sided acute subdural hematoma are unchanged in size and extent. There\n is decrease in cerebral edema and decrease in mass effect with better\n visualization of the basal cisterns compared to the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-05-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1011656, "text": " 3:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old man with traumatic IPH, SAH and basilar skull fracture\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 18-year-old man with traumatic ICH. Evaluate for interval\n change.\n\n COMPARISONS: , at 8:11 a.m.\n\n CT HEAD WITHOUT CONTRAST: The small right subdural hematoma overlying the\n right frontal convexity measures stable 4 to 5 mm in thickness, essentially\n unchanged. There is stable, very mild 2 to 3 mm leftward subfalcine\n herniation. The right frontal intraparenchymal hemorrhage and mild\n surrounding vasogenic edema is unchanged. Blood products in the left sphenoid\n sinus are unchanged. Mild left posterior parietal scalp hematoma is again\n noted. The known skull base fracture is not well demonstrated on this study\n without thin cut reconstructions.\n\n IMPRESSION: No significant interval change since . Stable right\n frontal intraparenchymal and right frontal subdural hemorrhages. No new\n hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2190-05-06 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1011449, "text": " 6:04 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: eval fx's\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18M s/p fall\n REASON FOR THIS EXAMINATION:\n eval fx's\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 18-year-old male, status post fall. Please evaluate for\n fracture.\n\n FINDINGS: A single portable supine chest radiograph is reviewed without\n comparison. Evaluation is limited by overlying trauma board.\n Cardiomediastinal silhouette is normal. Lungs are clear. There is no pleural\n effusion or pneumothorax. No fractures are seen.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-05-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1011524, "text": " 8:14 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: increased edema?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old man with ICH\n REASON FOR THIS EXAMINATION:\n increased edema?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage querying increased edema.\n\n COMPARISON: , 0143 and .\n\n CT HEAD WITHOUT IV CONTRAST: Again seen is a small subdural hematoma over the\n right frontal convexity measuring to 4.2 mm, essentially unchanged from the\n study seven hours previously. Leftward subfalcine herniation measures 2-3 mm,\n essentially unchanged from prior. Again seen is a 3.2 cm AP right frontal\n intraparenchymal hemorrhage, unchanged from prior with associated vasogenic\n edema. Hyperattenuating material within the left sphenoid is again seen,\n likely blood. A left posterior parietal scalp soft tissue swelling is again\n seen. There is no new intracranial hemorrhage. The ventricles, sulci and\n cisterns are essentially unchanged from a study seven hours earlier. Mastoid\n air cells are clear. The previously described skull base fractures are not\n well demonstrated on this study without dedicated bone windows; refer to study\n of for further details.\n\n IMPRESSION: Stable appearance of small subfalcine herniation, right subdural\n and right frontal intraparenchymal hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-05-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1011450, "text": " 6:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18M s/p skateboard fall, injury to scalp\n REASON FOR THIS EXAMINATION:\n eval ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:42 PM\n Small acute right subdural hematoma. Right inferior frontal intraparenchymal\n hemorrhage, and traumatic subarachnoid. Local mass effect and effacement of\n occipital of right lateral ventricle, and slight effacement of\n suprasellar cistern consistent with early uncal herniation. 4 mm leftward\n subfalcine herniation.\n\n Blood in sphenoid sinus, and probable skull base fracture - not well\n visualized, but likely through anterior clivus and left sphenoid \n WET READ VERSION #1 6:31 PM\n Small acute right subdural hematoma. Right inferior frontal intraparenchymal\n hemorrhage. Local mass effect and effacement of occipital of right\n lateral ventricle, and slight effacement of suprasellar cistern. 4 mm\n leftward subfalcine herniation.\n WET READ VERSION #2 6:39 PM\n Small acute right subdural hematoma. Right inferior frontal intraparenchymal\n hemorrhage, and traumatic subarachnoid. Local mass effect and effacement of\n occipital of right lateral ventricle, and slight effacement of\n suprasellar cistern consistent with early uncal herniation. 4 mm leftward\n subfalcine herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 18-year-old male status post skateboard fall, and injury to\n scalp. Please evaluate for intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a small acute right subdural hematoma, extending over the\n right cerebral convexity. This measures 5 mm in greatest axial dimension.\n There is also a moderate amount of intraparenchymal hemorrhage in the basal\n right frontal lobe, along the gyrus rectus, measuring 3.8 x 1.2 cm. There is\n also a moderate amount of traumatic subarachnoid hemorrhage seen layering\n along basal sulci.\n\n Associated with these traumatic injuries is a moderate amount of local edema,\n with mass effect and effacement on the occipital of the right lateral\n ventricle, and 4-mm leftward subfalcine herniation. Note is made of asymmetry\n within the prepontine cisterns, due to early right uncal herniation, evidenced\n by subtle effacement of the suprasellar cistern.\n\n There is no evidence of acute vascular territorial infarction.\n (Over)\n\n 6:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is diastasis of the left occipito-mastoid suture, and likely\n longitudinally oriented fracture extending through the left temporal bone.\n This extends through the petrous apex into the sphenoid sinus, where there is\n a moderate amount of blood, and a small focus of non-dependent air. Small\n focus of air is seen in the left carotid canal.\n\n Small amount of blood is also seen in the anterior ethmoid air cells on the\n left. There is a small mucous retention cyst in the floor of the left\n maxillary sinus. No additional fractures are seen. There is a moderate scalp\n contusion and laceration overlying the left parietal bone posteriorly.\n\n IMPRESSION:\n\n 1. Small acute right subdural hematoma, with traumatic subarachnoid\n hemorrhage and right inferior frontal intraparenchymal hemorrhage. Together,\n these exert moderate local mass effect, with 4-mm leftward subfalcine\n herniation, and likely early right uncal herniation.\n\n 2. Left skull base fracture, extending from diastasis of the left occipital\n mastoid suture, through the left temporal bone, left petrous apex, and\n terminating in the sphenoid sinus, which is opacified with blood. Small focus\n of air is seen in the left carotid canal, with fracture extending through this\n region, and CTA is recommended to exclude injury to the carotid artery.\n\n" }, { "category": "Radiology", "chartdate": "2190-05-06 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1011451, "text": " 6:04 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18M s/p skateboard fall, injury to scalp\n REASON FOR THIS EXAMINATION:\n eval c spine for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:36 PM\n no fracture or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 18-year-old male status post skateboard fall, and injury to\n scalp. Please evaluate for cervical spine fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast CT of the cervical spine, with multiplanar\n reformations.\n\n FINDINGS: There is no fracture or cervical spine malalignment. Prevertebral\n and paraspinal soft tissues are normal. Visualized outline of the thecal sac\n appears unremarkable, but please note that CT is unable to provide intrathecal\n detail comparable to MRI.\n\n Incidental note is made of blood within the sphenoid sinus, and left skull\n base fracture, described in detail on separately performed head CT.\n\n IMPRESSION: No cervical spine fracture or malalignment.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-09 00:00:00.000", "description": "Report", "row_id": 1659630, "text": "T/SICU NSG NOTE\n0700>>\n\nEVENTS: transfer from unit deferred; to remain overnight to continue monitoring neuro status for deterrioration now that mannitol is discontinued.\n\nNEURO- patient able to sleep in hour intervals today. Patient is confused to place and occasionally time with initial waking but is easily reoriented. He continues to have short term memory issues. He is generally cooperative with care and attempts to be independent. He remains impulsive and pulls at lines and tubes without first inquiring about items, but remains apologetic when he is caught attempting to disengage from these items. He again removed his IV catheter claiming he thought it was a bug. He admitted that he feels uncomfortable being attached to all the monitoring equipment and iv tubing. His neuro exam is unchanged: mae's, following commands, perrl, clear articuate speech with some confabulating when first awkening from a deep sleep.\nHe continues to complain of a persistent HA the is global, dull and sometimes sharp & achy all at the same time. The pain intensity ranges to following percocet (2 tablets). He supplements with PCA dilaudid: see careview pain assessment area.\nMannitol therapy discontinued- last dose @ 0400 ; serum osmalality 284 at 0930.\nNo seizure activity noted. Dilantin dosing changed to po route.\n\nCVS- stable vital signs with blood pressure remaining below maximum range of 140/systolic.\n\nRESP- no issues; room air with adequate saturations; no respiratory distress.\n\nRENAL- voiding upon request x2 today: clear yellow urine in large volume. IVF @ kvo. Fluid restriction remains in effect at 1 Liter/day for hyponatremia(132).\n\nGI- regular diet but no significant intake due to no appetite. Patient tolerates fluids without problem. PPI continues- changed to oral route. Receiving colace; no BM yet. No nausea/vomiting issues today.\n\nID- afebrile\n\nENDO- no issues\n\nSKIN- healing facial abraisions and posterior head laceration.\n\n mother at bedside most of the day assisting in patient supervision. Sitter ordered by ICU resident; obtained for evening & night shifts. Plan of care addressed and updated for mother with understanding confirmed.\n\nASSESS- 18 yo male s/p fall with closed head trauma and basal skull fracture. Stable neuro exam. Persistent HA with improved pain management and lower level of pain rating. Patient able to obtain effective intervals of sleep with positive effect on patient's behavior apparent: more cooperative and calm.\n\nPLAN- continue to monitor for neuro changes with mannitol therapy discontinued. Reassess for transfer to floor in am.\n continue with pain mangement regimen\n assist with periods of sleep\n sitter and/or increased surveillence to maintined safety and integrity of tubes and monitoring equipment.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-10 00:00:00.000", "description": "Report", "row_id": 1659631, "text": "TSICU Progress Note 1900-0700\n Sleeping in long naps overnight, improving neuro status.\n ROS-\n Neuro-Alert,orientedx3, some STM lapses but overall improving. Less impulsive, no pulling at lines, c/o persistent headache, Percocet given ATC, dilaudid used w/reminders, mother at bedside activating PCA for pt.\n CV-MP SB 40-60, no VEA.BP stable, <140 w/out intervention.Pulses+,SCD's in place.Peripheral line x1, kvo ivf\n Resp- roomair, no distress, sao2>95%.LS clear\n GI- Fluids taken qs(1000cc restriction maintained). No food taken except banana. No nausea/vomiting\n GU- HNV\n labs- Na 133 this am(132), Hct 40, glucose normal\n Plan- monitor neuro status\n pain control\n T to floor/SDU\n\n" }, { "category": "Nursing/other", "chartdate": "2190-05-07 00:00:00.000", "description": "Report", "row_id": 1659625, "text": "Nursing Admission Note\nNursing Admission Note to TSICU:\n\nSee Carevue for Specific Data.\n\n18yo male s/p fall while skateboarding at home in afternoon. Pt lost consciousness for about 5 minutes, was medflighted to .\nCT scan showed: small acute right subdural hematoma, right inferior frontal intraparenchymal hemorrhage, traumatic subarachnoid, blood in sphenoid sinus, basal skull fx.\n\nNeuro Exam: Pt is often alert, arouses to voice when sleeping. Pt follows all commands but sometimes requires asking twice/encouraging to focus. Pt with full strength, has full sensation everywhere. Pupils 5-7mm, equal, briskly reactive. Pt is rarely inappropriate-swearing/refusing care, but generally calm and confused. Pt asking repeated questions about toileting, taking collar off, and headache pain, teaching about environment reinforced. Pt oriented x3 usually, but does not remember accident. Pt occasionally needs to be reminded that he is in the hospital. Clear speech. Q1 hr neuro checks unchanged throughout evening. CT scans x3 since admission to -next CT scan planned for 08:00. Mannitol/Dilantin started. No seizure activity.\n\nPain: Pt c/o HA pain-given 1 dose dilaudid with good effect-pt calmed and had no pain, rested comfortably but arose to voice. Pt also given 2 tabs oxycodone with adequate relief. 50-100 mcg fentanyl IVP given with good relief of pain.\n\nCV: Hr 50-60's, no ectopy, SB. NBP 100-130 systolic, goal: systolic <140 maintained (nicardipine gtt ordered-not used). Easily palpable pedal pulses, PBoots on.\n\nResp: No oxygen therapy needed, maintaining O2 sats >96% on RA. Lung sounds clear throughout. +cough.\n\nGI: Abdomen soft, not distended, nontender, hypoactive bowel sounds, no BM overnight, colace given. Sips H2O with pills- tolerating well. Protonix for GI prophylaxis.\n\nGU: Adequate clear, light yellow urine through foley qhour.\n\nEndo: 2 units regular insulin per RISS administered.\n\nID: Afebrile, no antibiotics.\n\nSkin: Small posterior head lac-not sutured, draining scant serosanguinous fluid. Abrasion under left eye-red with scant serosanguinous drainage, both open to air. Back intact. Small abrasion seen on left elbow and left knee, no drainage.\n\nSocial: Father dies 4 years ago from traumatic brain injury-fell off horse. Mother stayed overnight, taking anti-anxiolytics to cope. Talked with this RN about coping, disease process, appropriate. brother flying in to town today, grandparents coming tomorrow. Mother has adequate support from friends, family.\n\nPlan: CT scan planned 08:00 this AM. Continue q1hr neuro checks. Tighten insulin sliding scale? Continue to support pt and family. Manage pain as needed.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-07 00:00:00.000", "description": "Report", "row_id": 1659626, "text": "Nursing (0700-1900)\nSee flowsheet for details.\n\nEVENTS:\nRepeat (pt's forth) CT this a.m.\n\nNeuro exam is WNL, however short term memory often poor. Pt. asking certain questions more than once. Otherwise no focal deficits noted. Repeat CT \"slightly improved\" per team, neuro check to Q2hrs. Pt. having frequent pain complaint - \"at the base of my skull, moving into my brain\" - treated largely ineffectively as noted. Pt. frequently asking classification of drugs given \"as these opiate based\" and also has stated more than once \"give me the strongest narcotic that you have\". ?Seeking element. Pt. did actually have best relief from tylenol. Mannitol Q6 with minimal diuresis noted.\n\nPhysical abd. assessment neg, however pt. did have 2 episodes of bilious emesis in small amts. today (the first prior to CT). Team is aware. The second episode was after drinking water.\n\nMother at bedside most of day, attempt to limit-set have been only somewhat effective. SS involved due to tramatic event. Family friends in for support as well. Mom will spend the night again.\n\nA/P:\nStable neuro exam and CT s/p TBI.\nCont. neuro exams Q2hr. Pain control. Limit setting to pt. and family continues. To stay ICU tonight per Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2190-05-07 00:00:00.000", "description": "Report", "row_id": 1659627, "text": "Addendum\nOngoing ineffective pain treatments continue as noted, pt. escalating, becoming agitated, etc. Pt. is making occ. remark this eve about \"chewing pills\" to make them \"work faster\" and this is a known recreational way to abuse oxycontin. This was addressed and pt. cont's to deny drug use.\n\nMother insisted to stay in room for foley removal, and has offered to help her son with voiding in urinal. Addressed with SS.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-08 00:00:00.000", "description": "Report", "row_id": 1659628, "text": "Nursing Progress Note, 1900-0730\nPlease refer to careview for specifics.\n\nSHIFT EVENTS: Pt on Q2H neuro exams & cont to have issues with pain control despite medicinal and theraputic interventions.\n\nROS:\n\nRESP: SV on RA, RR 16-20, SpO2 94-98%, LS clear bilaterally. Denies SOB or dyspnea.\n\nCVS: SB to SR, no ectopy, HR 42-72, NIBP 106-134/42-91, MAP > 60, afebrile, no anbx ordered at this time. Hct 36.6, WBC 10.3, INR 1.2. PIV x2 for access. + pedal pulses, skin intact except for abrasion noted beside L eye. Heparin held due to head bleed.\n\nNEURO: Q2H neuro exams, GCS 15, a+ox3, occasionally uses incoherent sentences & displays some short term memory loss. Pt dozing majority of night. Follows commands appropriately, MAEs with normal and equal strength, pupils 3-4mm, equal and briskly reactive. Reflexes intact. Complaining of constant/sharp headache, pt receiving percocet & fentanyl as ordered and still complaining of discomfort (although able to sleep for period of time). NSurg does not want pt to receive any other pain medications as they may interfere with neuro exams. Pt uses illicit drugs- i.e. marijuana, pt did not specify other drugs used. Pt receiving mannitol & dilantin for seizure prophylaxis. Current Na 137, Serum Osmo 284. Mother at bedside for comfort. Pt scheduled for repeate head CT this am.\n\nGI/GU: Abd soft, NT, ND, no BM or flatus, NPO- although tol sips of H20 w/ PO meds. Pt c/o nausea x1- given 4mg zofran IVP with relief of nausea. Blood sugars wnl, no insulin required per RISS. Pt using bedside urinal, no uop overnoc- pt denies urge to void. Lytes wnl. Receiving 20mEq KCL in NS at 75cc/hr.\n\nSOCIAL: Mother at bedside for comfort, although pt is 18 yrs of age. Pt and family have been updated as to pts status and POC.\n\nPOC: hemodynamics, Q2H neuro exams- ? advance to Q4H as neuro exams have been stable, cont mannitol & dilantin for seizure prophylaxis, monitor Na & Serum Osmos while pt cont to receive mannitol, cont pain mgmt, encourage pt to void, cont to provide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2190-05-08 00:00:00.000", "description": "Report", "row_id": 1659629, "text": "Events: Repeat Head CT this am. Dilaudid PCA initiated for pain control.\n\nNeuro: Frequently forgetful of reason for hospitalization. Periodically taking off equipment and pulled out IV. Consistently oriented x 3, able to count backwards from 10, MAE with equal strength and perrl. Headache persistent ranging form most of the day. PCA dilaudid added and percocet 2tabs given q4hr with pain level down to 4 this pm.\n\nCV: SR/no ectopy sbp 120/55\n\nPulm:RA sat 100%, respiratory effort unlabored. Lungs clear bilaterally.\n\nGU: Voiding 300cc+ every few hours.\n\nGI: Abd soft, bs present. Rare wave of nausea resolved spontaneously.\n\nFEN: Currently on fluid restriction for serum NA 131. Had been taking CL without difficulty prior to this.\n\nEndo: No coverage required\n\nSoc: Mother or brother at bedside most of the day. Mother was suddenly widowed four years ago and states strongly her need to stay with the patient.\n\nP: Continue neuro checks q2hrs, prn percocet for pain. Reorient and reinforce information as indicated. Continue fluid restriction and follow serum sodiums. Advance acitivty/diet as ordered and tolerated. Support family, validate feelings/concerns. ? transfer to step down if am if appropriate.\n" } ]

[ { "category": "Radiology", "chartdate": "2192-09-21 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1161536, "text": " 2:05 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: assess for carotid stenosis, pre op for CABG\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with 3 vessel CAD, planned CABG \n REASON FOR THIS EXAMINATION:\n assess for carotid stenosis, pre op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason:66 year old man with 3 vessel CAD, pre/op for CABG.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque in the ICA. On the left there is\n mild heterogeneous plaque in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 70/15, 74/15, 28/9, cm/sec. CCA peak systolic\n velocity is 118 cm/sec. ECA peak systolic velocity is 85 cm/sec. The ICA/CCA\n ratio is .62. These findings are consistent with <40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 68/15, 79/20, 57/18, cm/sec. CCA peak systolic\n velocity is 126 cm/sec. ECA peak systolic velocity is 106 cm/sec. The ICA/CCA\n ratio is .62. These findings are consistent with <40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA stenosis <40%.\n Left ICA stenosis <40%.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-09-24 00:00:00.000", "description": "L ELBOW (AP, LAT & OBLIQUE) LEFT", "row_id": 1161962, "text": " 2:18 PM\n ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: Evidence of fracture in patient s/p fall with continued pain\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with STEMI and fall, continued pain in L elbow.\n REASON FOR THIS EXAMINATION:\n Evidence of fracture in patient s/p fall with continued pain?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall and pain in left elbow.\n\n Three radiographic views were obtained of the left elbow. No fractures,\n dislocations, degenerative disease or effusions. There is a soft tissue\n injury superficial to the proximal . There are prominent vascular\n calcifications in the forearm. No concerning lytic or sclerotic lesions.\n There are no radiopaque foreign bodies.\n\n IMPRESSION: No acute injury to the left elbow.\n\n" }, { "category": "Radiology", "chartdate": "2192-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161600, "text": " 8:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ST ELEVATED MYOCARDIAL INFARCTION\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with CAD, being considered for CABG\n REASON FOR THIS EXAMINATION:\n Pre-op assessment\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: CAD consider for CABG.\n\n Cardiomediastinal contours are normal. The lungs are clear. There is no\n pneumothorax or pleural effusion.\n\n IMPRESSION:\n No evidence of acute cardiopulmonary abnormality.\n\n" }, { "category": "Echo", "chartdate": "2192-09-21 00:00:00.000", "description": "Report", "row_id": 63912, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Right ventricular function.\nHeight: (in) 66\nWeight (lb): 186\nBSA (m2): 1.94 m2\nBP (mm Hg): 104/41\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 14:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The estimated pulmonary artery systolic pressure is\nnormal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global and\nregional biventricular systolic function.\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2192-09-20 00:00:00.000", "description": "Report", "row_id": 122290, "text": "Sinus rhythm with baseline artifact. Possible slight ST segment elevations in\nlead III and possibly lead aVF, although baseline artifact renders\ninterpretation difficult. Cannot exclude inferior wall injury pattern.\nAnterolateral loss of R waves. Cannot exclude anterolateral wall myocardial\ninfarction, age indeterminate. Delayed R wave progression which may be\nrelated to lead positioning. Low QRS voltage in the precordial leads. No\nprevious tracing available for comparison. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2192-09-25 00:00:00.000", "description": "Report", "row_id": 122291, "text": "Sinus rhythm. Left axis deviation. Compared to the previous tracing\nof there are more prominent ST-T wave changes in the inferior leads\nwith downsloping ST segment depression and T wave inversion in II, III, aVF,\nwhile the ST-T wave abnormalities recorded in leads V5-V6 have improved In the\ncontext of tall right precordial T waves, these findings suggest\ninferoposterior ischemia. Followup and clinical correlation are\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2192-09-21 00:00:00.000", "description": "Report", "row_id": 122292, "text": "Normal sinus rhythm. Compared to tracing # 1 no diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-09-20 00:00:00.000", "description": "Report", "row_id": 122293, "text": "Marked baseline artifact. Low voltage in the limb leads. ST-T wave changes\nare possible but uninterpretable in the limb leads, but there is mild\nST segment depression in leads V4-V6. Compared to the previous tracing\nof the ST segment depression is somewhat more prominent. No other\ndiagnostic interval change.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2148-04-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 457825, "text": "Chief Complaint:\n HPI:\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Please see resident H+P\n Please see resident H+P\n Please see resident H+P\n Review of systems:Unable to obtain secondary to MS. Mother reports\n that he only complained of cramping in his legs the night before\n otherwise no fever chills or pain.\n Flowsheet Data as of 04:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 94) bpm\n BP: 111/61(73) {111/56(69) - 111/61(73)} mmHg\n RR: 12 (11 - 12) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 417 mL\n Urine:\n 417 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -417 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n Gen: Jaundiced, unresponsive does try to open eyes to sternal rub\n HEENT: PERRL upon opening, Jaundiced, JVP unable to assess\n Heart: RRR s1s2 +s4 soft SEM apex holosystolic\n Lungs: CTA anteriorly\n Abd: Mild distension, soft, NT, ND high pitched abd sounds reducible\n unbilical hernia.\n Ext: + Bil LE edema\n Neuro: Sedated and unresponsive, PERRL, EOMI\n Labs / Radiology\n 94\n 22.9\n 7.7\n 1.8\n 5.6\n 124\n 8\n [image002.jpg]\n PT 19.9 INR 1.9\n Ascites tap cx negative 130 WBC\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 457992, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n mental status improving slowly\n U/S did not show significant pocket of fluid to do diagnostic\n paracentesis\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 78 K/uL\n 8.5 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: Urine Cx pending\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion. Has had BM and MS\n improving overnight.\n - titrate lactulose to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n - appreciate hepatology recs\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated, today normal.\n - can stop checking amylase / lipase\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n #. Hypothyroidism - cont home Levothyroxine\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n #. FEN - ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication -\n #. FULL CODE\n #. Dispo - MICU overnight, c/o to floor in AM\n ICU Care\n Nutrition:\n Comments: ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 457993, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n mental status improving slowly\n U/S did not show significant pocket of fluid to do diagnostic\n paracentesis\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN: Unresponsive but tries to open eyes to noxious stimuli, NAD\n HEENT: PERRL on opening, +icteric sclera\n NECK: supple, unable to assess JVP\n LUNGS: CTA bilat anteriorly\n HEART: RRR, nl S1-S2, +loud P2 +S4\n ABDOMEN: NABS, soft/NT, mildly distended w/ fluid wave, reducible\n umbilical hernia\n EXTREM: 3+ BLE edema to knees, 2+ pedal pulses\n NEURO: unresponsive, +asterixis\n SKIN: jaundiced, + spider angiomata\n Labs / Radiology\n 78 K/uL\n 8.5 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: Urine Cx pending\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion. Has had BM and MS\n improving overnight.\n - titrate lactulose to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n - appreciate hepatology recs\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated, today normal.\n - can stop checking amylase / lipase\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n #. Hypothyroidism - cont home Levothyroxine\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n #. FEN - ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication -\n #. FULL CODE\n #. Dispo - MICU overnight, c/o to floor in AM\n ICU Care\n Nutrition:\n Comments: ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 457998, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 78 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 457999, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose for reasons relating\n to going in for a therapeutic tap which he had on - had 7 L\n removed followed by 12 bags albumin. Fluid unremarkable including gram\n stain. Subsequently he was given an extra dose of lactulose by his\n mother last night, as well as codeine for cramping. This morning, he\n was found to be unresponsive by his mother. At OSH ( Hosp) VSS,\n Head CT negative, given lactulose, 500cc NS and 1unit PRBC for Hct 21\n and sent to .\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 78 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 458000, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose for reasons relating\n to going in for a therapeutic tap which he had on - had 7 L\n removed followed by 12 bags albumin. Fluid unremarkable including gram\n stain. Subsequently he was given an extra dose of lactulose by his\n mother last night, as well as codeine for cramping. This morning, he\n was found to be unresponsive by his mother. At OSH ( Hosp) VSS,\n Head CT negative, given lactulose, 500cc NS and 1unit PRBC for Hct 21\n and sent to .\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 78 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with PAHT\n who was in his USOH until this am when his mother found him\n unresponsive. In the context of missing lactulose yesterday (+/-\n codeine) this is likely hepatic encephalopathy in the absence of SBP or\n other infection. He is currently waking up but continues to be altered.\n He will require close attention, continued lactulose and consideration\n of empiric SBP coverage if there are new signs of infection. Agree with\n continuing outpatient meds via NG. Hold off on diagnostic para for now\n given his recent improvement. Will initiate DVT prophylaxis.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2148-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 457864, "text": "42yo pt w/ long hx of hep C and ETOH liver failure who is on the\n transplant list and who gets weekly paracentesis and had multiple ICU\n admissions in the recent past. He presented to ED\n after mother found him to be unresponsive @ home. Pt had been taking\n codeine for pain and was given 1mg Narcan enroute to and another\n 2mg when he arrived @ w/ no change in LOC. ABG's were fine and\n o2sat 98% on RA but placed on ventimask 30% for mental status issues.\n NGT placed and given 20g Lactulose, 30g kayexalate for K 5.8, 1Unit\n PRBC given enroute to for Hct @ 21. Foley placed and 22g\n IV. VSS but remained unresponsive when sent w/ EMS to for\n further care.\n Hepatic encephalopathy\n Assessment:\n Pt grimacing to pain w/ movement/turning and when stimulated w/ care\n being given, opens eyes rarely but not tracking or responding to\n commands. PERRL 5mm/brisk, some spontaneous movement in all\n extremeties. Pt yesterday had 7L removed w/ his weekly paracentesis\n and only missed one dose of Lactulose. No stool @ OSH and no stool in\n ICU to this point. Bilat lower extremities w/ +6 edema, skin and\n sclera jaundice. Ammonia level @ OSH was 307.\n Action:\n Started Lactulose 60mL Q2H (pt has dobhoff from previous admissions),\n labs sent, nasal swab sent, CXR done, attempts to arouse pt., place 20g\n PIV (in addition to 22g from OSH). Remains on RA w/ o2sat >97%.\n Response:\n +BS, no stool to this point, no change in LOC,\n Plan:\n Cont lactulose w/ goal x6 stools per day, monitor LOC, f/u on labs.\n Mother @ bedside.\n" }, { "category": "Nursing", "chartdate": "2148-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 457853, "text": "42yo pt w/ long hx of hep C and ETOH liver failure who is on the\n transplant list and who gets weekly paracentesis and had multiple ICU\n admissions in the recent past. He presented to ED\n after mother found him to be unresponsive @ home. Pt had been taking\n codeine for pain and was given 1mg Narcan enroute to and another\n 2mg when he arrived @ w/ no change in LOC. ABG's were fine and\n o2sat 98% on RA but placed on ventimask 30% for mental status issues.\n NGT placed and given 20g Lactulose, 30g kayexalate for K 5.8, 1Unit\n PRBC given enroute to for Hct @ 21. Foley placed and 22g\n IV. VSS but remained unresponsive when sent w/ EMS to for\n further care.\n Hepatic encephalopathy\n Assessment:\n Pt grimacing to pain w/ movement/turning and when stimulated w/ care\n being given, opens eyes rarely but not tracking or responding to\n commands. PERRL 5mm/brisk, some spontaneous movement in all\n extremeties. Pt yesterday had 7L removed w/ his weekly paracentesis\n and only missed one dose of Lactulose. No stool @ OSH and no stool in\n ICU to this point. Bilat lower extremities w/ +6 edema, skin and\n sclera jaundice. Ammonia level @ OSH was 307.\n Action:\n Started Lactulose 60mL Q2H (pt has dobhoff from previous admissions),\n labs sent, nasal swab sent, CXR done, attempts to arouse pt., place 20g\n PIV (in addition to 22g from OSH). Remains on RA w/ o2sat >97%.\n Response:\n +BS, no stool to this point, no change in LOC,\n Plan:\n Cont lactulose w/ goal x6 stools per day, monitor LOC,\n" }, { "category": "Nursing", "chartdate": "2148-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 457852, "text": "42yo pt w/ long hx of hep C and ETOH liver failure who is on the\n transplant list and who gets weekly paracentesis and had multiple ICU\n admissions in the recent past. He presented to ED\n after mother found him to be unresponsive @ home. Pt had been taking\n codeine for pain and was given 1mg Narcan enroute to and another\n 2mg when he arrived @ w/ no change in LOC. ABG's were fine and\n o2sat 98% on RA but placed on ventimask 30% for mental status issues.\n NGT placed and given 20g Lactulose, 30g kayexalate for K 5.8, 1Unit\n PRBC given enroute to for Hct @ 21. Foley placed and 22g\n IV. VSS but remained unresponsive when sent w/ EMS to for\n further care.\n Hepatic encephalopathy\n Assessment:\n Pt grimacing to pain w/ movement/turning and when stimulated w/ care\n being given, opens eyes rarely but not tracking or responding to\n commands. PERRL 5mm/brisk, some spontaneous movement in all\n extremeties. Pt yesterday had 7L removed w/ his weekly paracentesis\n and only missed one dose of Lactulose. No stool @ OSH and no stool in\n ICU to this point. Bilat lower extremities w/ +6 edema, skin and\n sclera jaundice. Ammonia level @ OSH was 307.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2148-04-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 457841, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose secondary to going in\n for a therapeutic tap which he had on the 7^th and had 4 L removed.\n Fluid unremarkable. Subsequently he was given an extra dose of\n lactulose by his mother last night and found to be unresponsive in the\n am. At OSH VSS, Head CT negative, given lactulose, 500cc NS and 1unit\n PRBC and sent to .\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n See resident H+P\n Past medical history:\n Family history:\n Social History:\n Please see resident H+P\n Please see resident H+P\n Please see resident H+P\n Review of systems:Unable to obtain secondary to MS. Mother reports\n that he only complained of cramping in his legs the night before\n otherwise no fever chills or pain.\n Flowsheet Data as of 04:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 94) bpm\n BP: 111/61(73) {111/56(69) - 111/61(73)} mmHg\n RR: 12 (11 - 12) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 417 mL\n Urine:\n 417 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -417 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n Gen: Jaundiced, unresponsive does try to open eyes to sternal rub\n HEENT: PERRL upon opening, Jaundiced, JVP unable to assess\n Heart: RRR s1s2 +s4 loud P2 soft SEM apex holosystolic\n Lungs: CTA anteriorly\n Abd: Mild distension, soft, NT, ND high pitched abd sounds reducible\n unbilical hernia.\n Ext: + Bil LE edema\n Neuro: Sedated and unresponsive, PERRL, EOMI\n Labs / Radiology: Chest Port NG in place, large PA otherwise clear\n 94\n 22.9\n 7.7\n 1.8\n 5.6\n 124\n 8\n [image002.jpg]\n PT 19.9 INR 1.9\n Ascites tap cx negative 130 WBC\n Assessment and Plan\n Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with PAHT\n who was in his USOH until this am when his mother found him\n unresponsive.\n -Will continue outpt meds\n -Will check diagnostic tap to rule out SBP from tap yesterday\n -Will give lactulose until 3BM and MS improves\n -Will initiate DVT prophylaxsis.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2148-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 457919, "text": "42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n .\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion.\n - lactulose q2hrs until BM, then titrate to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx tonight, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n .\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2148-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 457923, "text": "42yo pt w/ long hx of hep C and ETOH liver failure who is on the\n transplant list and who gets weekly paracentesis and had multiple ICU\n admissions in the recent past. He presented to ED\n after mother found him to be unresponsive @ home. Pt had been taking\n codeine for pain and was given 1mg Narcan enroute to and another\n 2mg when he arrived @ w/ no change in LOC. ABG's were fine and\n o2sat 98% on RA. 1Unit PRBC given enroute to for Hct @ \n 21. VSS but remained unresponsive when sent w/ EMS to for\n further care.\n Hepatic encephalopathy\n Assessment:\n At begin of shift, pt grimacing to pain w/ movement/turning and when\n stimulated w/ care being given, opens eyes, not following commands.\n Action:\n Lactulose 60mL given x2 overnight.\n Response:\n Pt having 3 very large stools ob+. Now with flexiseal in place with lg\n amt of golden liquid drainage. More awake this am, following commands,\n slightly confused. Following commands.\n Plan:\n Cont to titrate lactulose w/ goal x6 stools per day, monitor LOC, f/u\n on labs.\n" }, { "category": "Nursing", "chartdate": "2148-04-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 458044, "text": "HPI: Patient is a 42 yo male Hep C and ETOH cirrhosis on tx list with\n PHT who was in his USOH until the morning of when his mother found\n him unresponsive. He missed an AM dose of Lactulose for reasons\n relating to going in for a therapeutic tap which he had on - had 7\n L removed followed by 12 bags albumin. Fluid unremarkable including\n gram stain. Subsequently he was given an extra dose of Lactulose by\n his mother last night, as well as codeine for cramping. This morning,\n he was found to be unresponsive by his mother. At OSH ( Hosp)\n received narcan x2, VSS, Head CT negative. Ammonia level =307, given\n Lactulose, 500cc NS and 1unit PRBC for Hct 21 and sent to .\n 24 Hour Events:\n Received Lactulose q2 via NGT with improvement. Has Flexi-seal\n draining large amounts liquid stool.\n Diagnostic paracentesis not done because no tapable pocket on u/s and\n MS subsequently improved.\n Hepatic encephalopathy\n Assessment:\n Patient is alert, oriented to self. He knows it is Saturday but\n confused to date, month and year. He knows he is in . He is\n conversing normally with his mother and staff. Lactulose has been held\n this morning as patient is passing large amounts of liquid stool via a\n flexi-seal.\n Action:\n Lactulose Q2 hours held for large amounts of stool. To titrate dose to\n goal of 6 BM\ns per day.\n Response:\n Mental status continues to improve.\n Plan:\n To transfer to . Lactulose for goal of 6 BM\ns per day. Awaiting\n liver transplant.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n ENCEPHALOPHATHY\n Code status:\n Full code\n Height:\n Admission weight:\n 70.1 kg\n Daily weight:\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Precautions: No Additional Precautions\n PMH: ETOH, Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep-C and ETOH cirrhosis. Has weekly paracentesis.\n Awaiting liver transplant.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:51\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 10 insp/min\n Heart Rate:\n 84 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 360 mL\n 24h total out:\n 420 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 04:31 AM\n Potassium:\n 4.2 mEq/L\n 04:31 AM\n Chloride:\n 98 mEq/L\n 04:31 AM\n CO2:\n 23 mEq/L\n 04:31 AM\n BUN:\n 34 mg/dL\n 04:31 AM\n Creatinine:\n 1.2 mg/dL\n 04:31 AM\n Glucose:\n 103 mg/dL\n 04:31 AM\n Hematocrit:\n 25.6 %\n 04:31 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n #22G left hand, #20G right forearm, Foley cath, flexi-seal, pedi NGT\n right nare.\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU-788\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 458037, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose for reasons relating\n to going in for a therapeutic tap which he had on - had 7 L\n removed followed by 12 bags albumin. Fluid unremarkable including gram\n stain. Subsequently he was given an extra dose of lactulose by his\n mother last night, as well as codeine for cramping. This morning, he\n was found to be unresponsive by his mother. At OSH ( Hosp) VSS,\n Head CT negative, given lactulose, 500cc NS and 1unit PRBC for Hct 21\n and sent to .\n 24 Hour Events:\n Received lactulose q2 via ngt o/n with improvement.\n MELD= 28.\n Diagnostic paracentesis not done because no tapable pocket on u/s and\n MS subsequently improved.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n cipro\n Infusions:\n Other ICU medications:\n Other medications:\n lactulose\n rifaximin\n ursodiol\n inhalled iloprost\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: jaundiced\n Neurologic: + asterexis. AAOx2\n CV: regular s1 s2, no m/r/g\n Lungs: distant BS at bases\n ABD: +ascites, distended, small umbilical hernia (reducible)\n EXT: +1 edema\n Labs / Radiology\n 8.5 g/dL\n 78 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with PAHT\n who was in his USOH until this am when his mother found him\n unresponsive. In the context of missing lactulose (+/- codeine) this\n is likely hepatic encephalopathy in the absence of SBP or other\n infection. Now improved after lactulose.\n NEURO: transition to lactualose PO, rifamixin.\n CV: hemodynamically stable\n GI: ESLD team appreciated. On OLT list. Conintue post-pyloric tube\n feeds.\n ID: cipro prophylaxis.\n PPX: Heparin Sc, PPI.\n DISPO: To floor. Full code. On OLT list.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2148-04-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 458040, "text": "HPI: Patient is a 42 yo male Hep C and ETOH cirrhosis on tx list with\n PHT who was in his USOH until the morning of when his mother found\n him unresponsive. He missed an AM dose of Lactulose for reasons\n relating to going in for a therapeutic tap which he had on - had 7\n L removed followed by 12 bags albumin. Fluid unremarkable including\n gram stain. Subsequently he was given an extra dose of Lactulose by\n his mother last night, as well as codeine for cramping. This morning,\n he was found to be unresponsive by his mother. At OSH ( Hosp)\n received narcan x2, VSS, Head CT negative. Ammonia level =307, given\n Lactulose, 500cc NS and 1unit PRBC for Hct 21 and sent to .\n 24 Hour Events:\n Received Lactulose q2 via NGT with improvement. Has Flexi-seal\n draining large amounts liquid stool.\n Diagnostic paracentesis not done because no tapable pocket on u/s and\n MS subsequently improved.\n Hepatic encephalopathy\n Assessment:\n Patient is alert, oriented to self. He knows it is Saturday but\n confused to date, month and year. He knows he is in . He is\n conversing normally with his mother and staff. Lactulose has been held\n this morning as patient is passing large amounts of liquid stool via a\n flexi-seal.\n Action:\n Lactulose Q2 hours held for large amounts of stool. To titrate dose to\n goal of 6 BM\ns per day.\n Response:\n Mental status continues to improve.\n Plan:\n To transfer to . Lactulose for goal of 6 BM\ns per day. Awaiting\n liver transplant.\n" }, { "category": "Nutrition", "chartdate": "2148-04-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 458053, "text": "Subjective\n Unable to speak with patient\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 70.1 kg\n 20.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 86\n Diagnosis: Encephalopathy\n PMH : HCV, etoh cirrhosis on liver transplant list, pulmonary\n hypertension, ascites, recurrent hepatic encephalopathy, grade II\n esophageal varices, OSA, anxiety, hx of IVDU, osteoporosis, anemia,\n hypothyroid, pancreatitis gallstone\n Food allergies and intolerances: none noted\n Pertinent medications: zinc sulfate, vitamin D, calcium carbonate,\n omeprazole, lactulose\n Labs:\n Value\n Date\n Glucose\n 103 mg/dL\n 04:31 AM\n BUN\n 34 mg/dL\n 04:31 AM\n Creatinine\n 1.2 mg/dL\n 04:31 AM\n Sodium\n 132 mEq/L\n 04:31 AM\n Potassium\n 4.2 mEq/L\n 04:31 AM\n Chloride\n 98 mEq/L\n 04:31 AM\n TCO2\n 23 mEq/L\n 04:31 AM\n pH (urine)\n 6.5 units\n 07:15 PM\n Albumin\n 3.3 g/dL\n 04:31 AM\n Calcium non-ionized\n 9.2 mg/dL\n 04:31 AM\n Phosphorus\n 2.6 mg/dL\n 04:31 AM\n Magnesium\n 2.9 mg/dL\n 04:31 AM\n ALT\n 19 IU/L\n 04:31 AM\n Alkaline Phosphate\n 126 IU/L\n 04:31 AM\n AST\n 49 IU/L\n 04:31 AM\n Amylase\n 96 IU/L\n 04:31 AM\n Total Bilirubin\n 15.5 mg/dL\n 04:31 AM\n Current diet order / nutrition support: Nutren 2.0 at 30ml/hr x 24\n hours - provides 1440kcal and 58g protein\n NPO\n GI: Abdomen soft/distended with hyperactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, Diagnosis, on transplant\n list\n Estimated Nutritional Needs\n Calories: 1750-2100kcal (BEE x or / 25-30 cal/kg)\n Protein: 84-105 (1.2-1.5 g/kg)\n Fluid: noted fluid restriction of 1000ml\n Specifics:\n 42 year old male with history of etoh cirrhosis/HCV on transplant list\n presenting after being found unresponsive in setting of codeine and\n missed lactulose. Noted per chart, patient with improved mental status\n today. Tube feedings to start, but diet has not been advanced. Current\n tube feeding is appropriate once patient starts eating, if unable to\n take PO intake will need to increase goal of tube feeding to 40ml/hr x\n 24 hours to provide 1920kcal and 77g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as possible to vegetarian/low sodium\n 2. Start tube feedings of Nutren 2.0 to goal rate of 30ml/hr x 24\n hours\n 3. If unable to advance diet or patient is not taking PO intake,\n increase goal of tube feedings to 40ml/hr x 24 hours\n 4. Will follow for plan of care and make adjustments to tube\n feedings PRN\n 01:34 PM\n" }, { "category": "Physician ", "chartdate": "2148-04-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 457896, "text": "TITLE:\n Chief Complaint: unresponsive, encephalopathy\n HPI:\n Mr. is a 42-yo man with cirrhosis EtOH + HCV on transplant\n list, pulmonary HTN, severe diuretic refractory ascites, and recurrent\n hepatic encephalopathy, who presented to OSH after being found\n unresponsive by his mother. has been doing well at home since his\n last hospitalization (see d/c summary dated ), until this\n morning. He has been having weekly therapeutic paracenteses, and his\n most recent one was yesterday under ultrasound guidance. He had 7L of\n clear yellow ascites removed, and fluid analysis showed no evidence of\n SBP. He did receive 4 bags of albumin. Serum labs yesterday also showed\n hyponatremia of 124 and creatinine 1.8, so he was advised to stop his\n diuretic Aldactone. Per his mother, he missed his morning dose of\n lactulose because of the plan for the procedures, but did have two\n bowel movements in the morning. He received his PRN codeine for hand\n and feet cramps, so his mother gave him a double-dose of lactulose in\n the evening as well, since she \"knows that codeine binds him up\". He\n was still doing well at 3am when she checked on him overnight, but this\n morning he was unresponsive, so EMS was called.\n He was given Narcan 1mg IV en route to OSH ED without response. On\n arrival VS: Temp 96.5F rectal, BP 90/62, HR 90, R 20, SaO2 98% RA. He\n received an additional Narcan 2mg IV without effect. Labs were\n significant for WBC 5.8 w/ 87% PMNs and 2% bands, Hct 21.6, Plts 68; Na\n 128, K 5.8, Cr 2.0; TBili 9.6, Alb 3.1, INR 1.8, and Lipase 592. Serum\n EtOH was negative, and ABG was 7.54/27/484 on 100% FiO2. He also\n received IVF NS 500cc bolus, Lactulose 30ml, Kayexelate 30g, and 1unit\n PRBCs. He is transferred to MICU for further care.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS:\n Miconazole Nitrate 2% Powder 1 Appl Topical TID PRN\n Levothyroxine 88mcg PO DAILY\n Rifaximin 200mg PO TID\n Simethicone 40-80mg PO QID PRN gas pain\n Zinc Sulfate 220mg PO DAILY\n Ursodiol 600mg PO QAM\n Cholecalciferol (Vitamin D3) 800units PO DAILY\n Calcium Carbonate 500mg PO DAILY\n Omeprazole 20mg PO DAILY\n Midodrine 7.5mg PO TID\n Ciprofloxacin 500mg PO daily\n Lactulose 30-60ml PO QID: Titrate to >6 BM daily\n Iloprost 10mcg/mL Nebulizer 2.5 ml INH 6 times per day\n Magnesium Oxide 400mg PO BID\n Codeine sulfate 15-30mg PO BID PRN pain\n Oxygen 2L NC up to 8hrs / day (O2 sat at rest 98%, w/ activity 89%)\n .\n TUBE FEEDS: Nutren 2.0 Full strength; Starting rate: 30 ml/hr; Advance\n rate by 10 ml q4h Goal rate: 30 ml/hr; Hold feeding for residual >= :\n 100 ml; Flush w/ 30 ml water q4h; Other instructions: No residuals with\n post pyloric feeding tube\n Past medical history:\n Family history:\n Social History:\n - HCV and EtOH cirrhosis on transplant list\n - h/o SBP early on Cipro prophylaxis\n - Grade II esophageal varices\n - Recurrent hepatic encephalopathy on vegetarian diet\n - Pulmonary HTN\n - Obstructive sleep apnea\n - Hypothyroidism\n - Anxiety disorder\n - H/o EtOH abuse, IVDU\n - Osteoporosis of hip and spine per pt\n - Anemia w/ hx of guaiac positive stool\n Mother with DM and HTN. Father with rheumatic heart disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives with his mother. quit smoking , was smoking\n ppd. Quit drinking EtOH 11 years ago. Prior remote hx of IVD as\n teen. No current drug use.\n Review of systems:\n Flowsheet Data as of 08:21 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 79 (79 - 94) bpm\n BP: 109/63(73) {109/56(69) - 111/63(73)} mmHg\n RR: 11 (11 - 12) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 970 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 469 mL\n Urine:\n 469 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 501 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n VS: Temp 98.0F, HR 86, BP 111/56, R 11, SaO2 99%RA\n GEN: Unresponsive but tries to open eyes to noxious stimuli, NAD\n HEENT: PERRL on opening, +icteric sclera\n NECK: supple, unable to assess JVP\n LUNGS: CTA bilat anteriorly\n HEART: RRR, nl S1-S2, +loud P2 +S4\n ABDOMEN: NABS, soft/NT, mildly distended w/ fluid wave, reducible\n umbilical hernia\n EXTREM: 3+ BLE edema to knees, 2+ pedal pulses\n NEURO: unresponsive, +asterixis\n SKIN: jaundiced, + spider angiomata\n Labs / Radiology\n 82 K/uL\n 8.7 g/dL\n 116 mg/dL\n 1.5 mg/dL\n 35 mg/dL\n 23 mEq/L\n 96 mEq/L\n 5.0 mEq/L\n 130 mEq/L\n 25.7 %\n 7.3 K/uL\n [image002.jpg]\n \n 2:33 A5/8/ 05:00 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.3\n Hct\n 25.7\n Plt\n 82\n Cr\n 1.5\n Glucose\n 116\n Other labs: PT / PTT / INR:21.7/45.3/2.1, ALT / AST:16/43, Alk Phos / T\n Bili:128/13.5, Amylase / Lipase:105/65, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:236 IU/L, Ca++:9.2 mg/dL, Mg++:3.0 mg/dL, PO4:2.5 mg/dL\n Fluid analysis / Other labs: LABS FROM OSH:\n WBC 5.8, Hgb 7.5, Hct 21.6, Plt 68\n Diff: 87% PMNs, 2% bands, 7L, 4M\n INR 1.82\n Na 128, K 5.8, Cl 97, HCO3 22, Cr 2.0, Gluc 113; Ca 9.0, Mg 2.7\n LFTs: ALT 26, AST 43, Alk Phos 191, TBili 9.6, Conj Bili 2.5\n TProt 6.5, Alb 3.1, Lip 592\n Serum EtOH negative\n ABG: 7.54/27/484/23.1/100%\n Ammonia 307\n Imaging: TESTS FROM OSH:\n CXR: reportedly normal\n NCHCT: reportedly normal\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n .\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion.\n - lactulose q2hrs until BM, then titrate to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx tonight, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n .\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n .\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n .\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n .\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n .\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n .\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated.\n - cont to monitor\n .\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n .\n #. Hypothyroidism - cont home Levothyroxine\n .\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n .\n #. FEN - NPO, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication -\n #. FULL CODE\n #. Dispo - MICU overnight, c/o to floor in AM\n ICU Care\n Nutrition:\n Comments: NPO, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 458004, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n mental status improving slowly\n U/S did not show significant pocket of fluid to do diagnostic\n paracentesis\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT, PERRL/EOMI, +icteric sclera, MMM\n NECK: supple\n LUNGS: CTA bilat anteriorly\n HEART: RRR, nl S1-S2, +loud P2 +S4\n ABDOMEN: NABS, soft/NT, mildly distended w/ fluid wave, reducible\n umbilical hernia\n EXTREM: 3+ BLE edema to knees, 2+ pedal pulses\n NEURO: A&Ox3, +asterixis\n SKIN: jaundiced, + spider angiomata\n Labs / Radiology\n 78 K/uL\n 8.5 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: Urine Cx pending\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion. Has had BM and MS\n improving overnight.\n - titrate lactulose to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n - appreciate hepatology recs\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated, today normal.\n - can stop checking amylase / lipase\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n #. Hypothyroidism - cont home Levothyroxine\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n #. FEN - ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication -\n #. FULL CODE\n #. Dispo - MICU overnight, c/o to floor in AM\n ICU Care\n Nutrition:\n Comments: ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 458005, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n mental status improving slowly\n U/S did not show significant pocket of fluid to do diagnostic\n paracentesis\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT, PERRL/EOMI, +icteric sclera, MMM\n NECK: supple\n LUNGS: CTA bilat anteriorly\n HEART: RRR, nl S1-S2, +loud P2 +S4\n ABDOMEN: NABS, soft/NT, mildly distended w/ fluid wave, reducible\n umbilical hernia\n EXTREM: 3+ BLE edema to knees, 2+ pedal pulses\n NEURO: A&Ox3, +asterixis\n SKIN: jaundiced, + spider angiomata\n Labs / Radiology\n 78 K/uL\n 8.5 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: Urine Cx pending\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion. Has had BM and MS\n improving overnight.\n - titrate lactulose to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n - appreciate hepatology recs\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated, today normal.\n - can stop checking amylase / lipase\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n #. Hypothyroidism - cont home Levothyroxine\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n #. FEN - ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication\n w/ pt, mother\n #. FULL CODE\n #. Dispo - c/o to floor\n ICU Care\n Nutrition:\n Comments: ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 458018, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n mental status improving slowly\n U/S did not show significant pocket of fluid to do diagnostic\n paracentesis\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT, PERRL/EOMI, +icteric sclera, MMM\n NECK: supple\n LUNGS: CTA bilat anteriorly\n HEART: RRR, nl S1-S2, +loud P2 +S4\n ABDOMEN: NABS, soft/NT, mildly distended w/ fluid wave, reducible\n umbilical hernia\n EXTREM: 3+ BLE edema to knees, 2+ pedal pulses\n NEURO: A&Ox3, +asterixis\n SKIN: jaundiced, + spider angiomata\n Labs / Radiology\n 78 K/uL\n 8.5 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: Urine Cx pending\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion. Has had BM and MS\n improving overnight.\n - titrate lactulose to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n - appreciate hepatology recs\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated, today normal.\n - can stop checking amylase / lipase\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n #. Hypothyroidism - cont home Levothyroxine\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n #. FEN - ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication\n w/ pt, mother\n #. FULL CODE\n #. Dispo - c/o to floor\n ICU Care\n Nutrition:\n Comments: ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 458023, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose for reasons relating\n to going in for a therapeutic tap which he had on - had 7 L\n removed followed by 12 bags albumin. Fluid unremarkable including gram\n stain. Subsequently he was given an extra dose of lactulose by his\n mother last night, as well as codeine for cramping. This morning, he\n was found to be unresponsive by his mother. At OSH ( Hosp) VSS,\n Head CT negative, given lactulose, 500cc NS and 1unit PRBC for Hct 21\n and sent to .\n 24 Hour Events:\n Received lactulose q2 via ngt o/n with improvement.\n MELD= 28.\n Diagnostic paracentesis not done because no tapable pocket on u/s and\n MS subsequently improved.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n cipro\n Infusions:\n Other ICU medications:\n Other medications:\n lactulose\n rifaximin\n ursodiol\n inhalled iloprost\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.5 g/dL\n 78 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with PAHT\n who was in his USOH until this am when his mother found him\n unresponsive. In the context of missing lactulose yesterday (+/-\n codeine) this is likely hepatic encephalopathy in the absence of SBP or\n other infection. Now improved after lactulose.\n NEURO: transition to lactualose PO, rifamixin.\n CV: hemodynamically stable\n GI: ESLD team appreciated. On OLT list. Conintue post-pyloric tube\n feeds.\n ID: cipro prophylaxis.\n PPX: Heparin Sc, PPI.\n DISPO: To floor. Full code. On OLT list.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2148-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 458024, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 05:00 PM\n mental status significantly improved this morning\n U/S did not show significant pocket of fluid to do diagnostic\n paracentesis\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 99 (78 - 99) bpm\n BP: 94/63(70) {93/47(59) - 111/72(78)} mmHg\n RR: 15 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,090 mL\n 240 mL\n PO:\n TF:\n IVF:\n Blood products:\n 350 mL\n Total out:\n 584 mL\n 280 mL\n Urine:\n 584 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 506 mL\n -40 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT, PERRL/EOMI, +icteric sclera, MMM\n NECK: supple\n LUNGS: CTA bilat anteriorly\n HEART: RRR, nl S1-S2, +loud P2 +S4\n ABDOMEN: NABS, soft/NT, mildly distended w/ fluid wave, reducible\n umbilical hernia\n EXTREM: 3+ BLE edema to knees, 2+ pedal pulses\n NEURO: A&Ox3, +asterixis\n SKIN: jaundiced, + spider angiomata\n Labs / Radiology\n 78 K/uL\n 8.5 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.6 %\n 8.7 K/uL\n [image002.jpg]\n 05:00 PM\n 04:31 AM\n WBC\n 7.3\n 8.7\n Hct\n 25.7\n 25.6\n Plt\n 82\n 78\n Cr\n 1.5\n 1.2\n Glucose\n 116\n 103\n Other labs: PT / PTT / INR:21.0/53.6/2.0, ALT / AST:19/49, Alk Phos / T\n Bili:126/15.5, Amylase / Lipase:96/58, Differential-Neuts:88.0 %,\n Lymph:4.6 %, Mono:6.9 %, Eos:0.3 %, Lactic Acid:2.5 mmol/L, Albumin:3.3\n g/dL, LDH:228 IU/L, Ca++:9.2 mg/dL, Mg++:2.9 mg/dL, PO4:2.6 mg/dL\n Microbiology: Urine Cx pending\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n 42-yo man with cirrhosis EtOH & HCV on transplant list, pulm HTN,\n severe diuretic refractory ascites, and recurrent hepatic\n encephalopathy, who presented to OSH unresponsive in the setting of\n getting codeine and missing a dose of lactulose yesterday, found to\n have an elevated Ammonia and otherwise negative work-up for altered\n mental status.\n #. Hepatic encephalopathy - In the setting of getting codeine yesterday\n and missing a dose of lactulose, also suggested by elevated ammonia at\n OSH and fact that he has not moved bowels in >24hrs. Other\n possibilities include variceal bleeding or SBP. Had a paracentesis\n yesterday, with 7L fluid removed, and fluid analysis showing no\n evidence of SBP. Should consider possibilty of transient secondary\n bacterial peritonitis paracetnesis yesterday, but exam and labs\n today do not suggest infection. Regarding variceal bleeding, he has\n known grade II varices and h/o Guaiac-positive stools, but Hct was\n stable at OSH and he responded well to transfusion. Has had BM and MS\n improving overnight.\n - titrate lactulose to 6 BMs daily\n - cont home rifaximin\n - avoid narcotics\n - attempted U/S-assisted bedside diagnostic paracentesis, but no\n adequate pocket visualized for safe procedure\n - cont Cipro SBP ppx, consider change to CTX if any evidence of\n possible infection\n - Guaiac stools\n - cont home PPI\n - appreciate hepatology recs\n #. Cirrhosis/Liver failure - EtOH & HCV, inactive on transplant\n list. Has been c/b ascites, encephalopathy and SBP. MELD 28.\n - cont home for elevated bilirubin\n - cont to monitor LFTs, albumin, INR, Plts\n #. Anemia - Has h/o Guaiac positive stools, known Grade II varices. Hct\n stable at OSH, received 1unit PRBCs with appropriate response.\n - Guaiac stools\n - cont home PPI\n - active T&S, txf Hct <21\n - cont to monitor\n #. Hyponatremia - Improving after stopping diuretics.\n - cont to hold diuretics\n - cont to monitor\n #. Renal failure - Improving after IVF 500cc NS bolus at OSH.\n - cont home midodrine\n - cont to monitor\n #. Hyperkalemia - Noted on labs at OSH. Received Kayexelate x1 with\n improvement.\n - cont to monitor\n #. Pancreatitis - Pt has h/o pancreatitis, thought to be \n gallstones. Suggested by elevated lipase >500 at OSH. Amylase and\n lipase here only mildly elevated, today normal.\n - can stop checking amylase / lipase\n #. Pulmonary HTN - cont home Iloprost, supplemental O2 PRN\n #. Hypothyroidism - cont home Levothyroxine\n #. Obstructive sleep apnea - Seen previously by Dr. (),\n suggested settings for CPAP at night.\n - attempt CPAP at night if mental status improves and uses at\n home\n #. FEN - ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n replete lytes PRN\n #. PPx - SQ Heparin, pneumboots, home PPI\n #. Access - PIVs\n #. Communication\n w/ pt, mother\n #. FULL CODE\n #. Dispo - c/o to floor\n ICU Care\n Nutrition:\n Comments: ADAT, tube-feeds (post-pyloric Dobhoff placement confirmed),\n fluid restriction, replete lytes PRN\n Glycemic Control:\n Lines:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2148-04-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 457879, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose for reasons relating\n to going in for a therapeutic tap which he had on - had 7 L\n removed followed by 12 bags albumin. Fluid unremarkable including gram\n stain. Subsequently he was given an extra dose of lactulose by his\n mother last night, as well as codeine for cramping. This morning, he\n was found to be unresponsive by his mother. At OSH ( Hosp) VSS,\n Head CT negative, given lactulose, 500cc NS and 1unit PRBC for Hct 21\n and sent to .\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n See resident H+P\n Past medical history:\n Family history:\n Social History:\n Please see resident H+P\n Please see resident H+P\n Please see resident H+P\n Review of systems:Unable to obtain secondary to MS. Mother reports\n that he only complained of cramping in his legs the night before\n otherwise no fever chills or pain.\n Flowsheet Data as of 04:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 94) bpm\n BP: 111/61(73) {111/56(69) - 111/61(73)} mmHg\n RR: 12 (11 - 12) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 417 mL\n Urine:\n 417 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -417 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n Gen: Jaundiced, unresponsive does try to open eyes to sternal rub\n 19:00 opening eyes and tracking to verbal stimuli.\n HEENT: PERRL upon opening, Jaundiced, JVP unable to assess\n Heart: RRR s1s2 +s4 loud P2 soft SEM apex holosystolic\n Lungs: CTA anteriorly\n Abd: Mild distension, soft, NT, ND high pitched abd sounds reducible\n unbilical hernia.\n Ext: 3+ Bil LE edema\n Neuro: PERRL, EOMI\n Labs / Radiology: Chest Port NG in place, large PA otherwise clear\n 82\n 25.7\n 8.7\n 23\n 5.0\n 130\n 7.3\n [image002.jpg]\n PT 19.9 INR 1.9, albumin 3.3\n Ascites tap cx negative 130 WBC\n Assessment and Plan\n Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with PAHT\n who was in his USOH until this am when his mother found him\n unresponsive. In the context of missing lactulose yesterday (+/-\n codeine) this is likely hepatic encephalopathy in the absence of SBP or\n other infection. He is currently waking up but continues to be altered.\n He will require close attention, continued lactulose and consideration\n of empiric SBP coverage if there are new signs of infection. Agree with\n continuing outpatient meds via NG. Hold off on diagnostic para for now\n given his recent improvement. Will initiate DVT prophylaxis.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Patient is critically ill. Total time spent:34 minutes\n ------ Protected Section ------\n Addendum: acute anemia, possibly due to bleeding. Will follow Hct and\n guaiac stool with next bowel movement. He also has mild-mod OSA based\n on a portable inpatient sleep study. Reviewing his CPAP titration\n study, autoset CPAP 12-14cm was recommended. It\ns not clear from the\n notes if this was ever intitiated. Will hold off on CPAP tonight given\n his altered MS but this will need to be addressed prior to discharge.\n If he never started it, this can/should be ordered as long as Mr \n is willing to use it at home.\n Regarding his pancreatitis, lipase is at his baseline. Creatinine has\n improved since this AM.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:14 ------\n" }, { "category": "Physician ", "chartdate": "2148-04-26 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 457872, "text": "I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan as detailed in my note below.\n Chief Complaint: Decreased MS\n HPI:Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with\n PHT who was in his USOH until this am when his mother found him\n unresponsive. He missed an AM dose of lactulose for reasons relating\n to going in for a therapeutic tap which he had on - had 7 L\n removed followed by 12 bags albumin. Fluid unremarkable including gram\n stain. Subsequently he was given an extra dose of lactulose by his\n mother last night, as well as codeine for cramping. This morning, he\n was found to be unresponsive by his mother. At OSH ( Hosp) VSS,\n Head CT negative, given lactulose, 500cc NS and 1unit PRBC for Hct 21\n and sent to .\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n See resident H+P\n Past medical history:\n Family history:\n Social History:\n Please see resident H+P\n Please see resident H+P\n Please see resident H+P\n Review of systems:Unable to obtain secondary to MS. Mother reports\n that he only complained of cramping in his legs the night before\n otherwise no fever chills or pain.\n Flowsheet Data as of 04:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 94) bpm\n BP: 111/61(73) {111/56(69) - 111/61(73)} mmHg\n RR: 12 (11 - 12) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 417 mL\n Urine:\n 417 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -417 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n Gen: Jaundiced, unresponsive does try to open eyes to sternal rub\n 19:00 opening eyes and tracking to verbal stimuli.\n HEENT: PERRL upon opening, Jaundiced, JVP unable to assess\n Heart: RRR s1s2 +s4 loud P2 soft SEM apex holosystolic\n Lungs: CTA anteriorly\n Abd: Mild distension, soft, NT, ND high pitched abd sounds reducible\n unbilical hernia.\n Ext: 3+ Bil LE edema\n Neuro: PERRL, EOMI\n Labs / Radiology: Chest Port NG in place, large PA otherwise clear\n 82\n 25.7\n 8.7\n 23\n 5.0\n 130\n 7.3\n [image002.jpg]\n PT 19.9 INR 1.9, albumin 3.3\n Ascites tap cx negative 130 WBC\n Assessment and Plan\n Patient is a 42 yo male Hep C and etoh cirrhosis on tx list with PAHT\n who was in his USOH until this am when his mother found him\n unresponsive. In the context of missing lactulose yesterday (+/-\n codeine) this is likely hepatic encephalopathy in the absence of SBP or\n other infection. He is currently waking up but continues to be altered.\n He will require close attention, continued lactulose and consideration\n of empiric SBP coverage if there are new signs of infection. Agree with\n continuing outpatient meds via NG. Hold off on diagnostic para for now\n given his recent improvement. Will initiate DVT prophylaxis.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 03:59 PM\n 20 Gauge - 03:59 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Patient is critically ill. Total time spent:34 minutes\n" }, { "category": "Radiology", "chartdate": "2148-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1077514, "text": " 5:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of Dobhoff.\n Admitting Diagnosis: ENCEPHALOPHATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42-yo man w/ hepatic encephalopathy (EtOH + HCV cirrhosis), pulm HTN, here\n unresponsive, also w/ chronic Dobhoff in place.\n REASON FOR THIS EXAMINATION:\n eval placement of Dobhoff.\n ______________________________________________________________________________\n WET READ: PXDb FRI 5:44 PM\n Feeding tube enters the duodenum and then out of the field of view, low lung\n volumes with infrahilar linear opacities R>L, likely atelectasis given low\n lung volumes, otherwise, unremarkable study. ( )\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old patient with hepatic encephalopathy and pulmonary\n hypertension, here unresponsive, also with chronic Dobbhoff in place. Evaluate\n placement of Dobbhoff.\n\n COMPARISON: Prior chest radiographs from .\n\n PORTABLE AP CHEST RADIOGRAPH: Feeding tube can be followed throughout the\n stomach, duodenum, Treitz, to the proximal jejunum and then out of the field\n of view. Low lung volumes. No pleural effusion or pneumothorax.\n Cardiomediastinal silhouette is unremarkable.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2176-05-12 00:00:00.000", "description": "Report", "row_id": 1543945, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT , ALERT, OX3, MAE, FOLLOWS COMMANDS. PT C/O MILD DISCOMFORT FROM CELLULITIS, ICE PACKS GIVEN. PT REQUESTED ATIVAN THIA AM. 1MG PO GIVEN.\n\nRESP: PT REMAINS ON RA W/ SATS 9=100%. PT MILDLY SOB WHEN OOB TO COMMODE. LS CLEAR.\n\nCV: HR 90-100'S NSR. SBP 100-130'S. TMAX 100.6. PT GIVEN 1 BAG PLTS FOR PLT COUNT 9, POST TRANSFUSION 40. PT GIVEN 15MMOL KPHOS OVERNGIHT. AM LABS PENDING.\n\nGI/GU: ABD SOFT, +BS, +BM SMALL AMT LOOSE STOOL X2. PT TOLERATING . PT VOIDING IN COMODE USING PERI BOTTLE W/ WARM SOAPY WATER TO CLEAN, NOT ABLE TO WIPE. CELLULITIS AREA W/ NO CHANGE FROM MARKINGS.\n\nACCESS: PORTACATH IN LEFT SCL. MEDIAL ACCESS SIDE NOT DRAWING BACK, LATERAL ACCESS SIDE DRAWS BACK WELL. #18 IN RIGHT AC.\n\nDISPO: PT HAD A GOOD NIGHT. PLAN IS TO CHECK AM LYTES. MONITOR HCT AND PLT COUNT. PT SHOULD BE TRANSFERED TO 7 TODAY. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2176-05-11 00:00:00.000", "description": "Report", "row_id": 1543943, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT , COOPERATIVE, AOX3. PT DENIES ANY PAIN, ONLY DISCOMFORT WHEN MOVING TOO AND FROM COMMODE.\n\nRESP: PT ON RA, O2 SATS 97-100%. LS CLEAR.\n\nCV: HR 90-110'S NSR. SBP 90-120'S. TMAX 103.6 TYLENOL GIVEN X2, AM TEMP 97. PM LABS, REPLEATED K+ 3.6, MAG 1.7, CA 7 AND PHOS 1.9. PM HCT 23 W/ NO BUMP FROM AFTERNOON TRANSFUSION. 1 UNIT PRBC'S GIVEN OVERNIGHT. ALL AM LABS PENDING.\n\nGI/GU: ABD SOFT, +BS, +BM. PT TOLERATING . PT ON NEUTROPENIC PRECAUTIONS, BOTTEL WATER IN PT'S ROOM. PT VOIDING ON COMODE. LABIA RED SWOLLEN, APPEARS NO CHANGE FROM MARKINGS. PT USING 60CC SYRINGE W/ WARM WATER TO CLEAN AREA.\n\nENDO: PT STARTED ON RISS. 2400 153 COVERED W/ 2 UNITS.\n\nACCESS: PT HAS #18, SLIGHTLY RED AT SITE, DRAW AND FLUSHES WELL. PORTACATH LEFT SCL. DRAWS WELL.\n\nDISPO: CONT TO MONTIOR TEMPS, IV ANTIBIOTICS. AWAITING AM LABS. NO CONTACT FROM FAMILY OVERNIGHT. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2176-05-11 00:00:00.000", "description": "Report", "row_id": 1543944, "text": "NPN 7a-7p:\n Please see nursing transfer note for details of admit, micu course and review of systems for today. To Add: pt with 2 episodes SVT 150's-160's (sbp 1teens to 130's throughout) this afternoon, the first resolving to NSR with carotid massage by Resident. pt with repeat episode sustained SVT requiring 6mg iv adenosine with immediate conversion to nsr. sbp 1teens to 130's. lytes sent stat. K+ 4.0. Mg 1.7, receiving 3 amps MGso4 over 2 hrs. albumin added to correct calcium. await Kphos from pharmacy as phos 1.6. plan to start lopressor 12.5 po bid after plt infusion. IN past pt required transient therapy with lopressor when volume overloaded post chemo d/t hypertension until pt had been diureses. Of note, pt is autodiuresing.. is allergic to iv lasix. Repeat plt count this afternoon 9K. pt with small amt epistaxis, stopped without intervention. pt premed with 650mg po tylenol, 50mg po benadryl and 100mg iv hydrocortisone (h/o reaction in past with hives) and 1 bag single donor plts up to infuse over 1 hr. Per onc team, blood cx from POC were + for GNR in EW. please rotate ports of double lumen catheter so that both resevoirs are exposed to abx.\nA/P: pt to remain in icu o/n for further monitoring. To be transferred to 7 tomorrow. bed is held.\n" }, { "category": "Nursing/other", "chartdate": "2176-05-10 00:00:00.000", "description": "Report", "row_id": 1543941, "text": "NURSING PROGRESS NOTE:\n PT IS VERY PLEASANT ALERT AND ORIENTED 63 YR OLD WOMAN WHO IS POSTMENAPAUSAL AND HAS A HX OF MANTLE CELL LYMPHOMA, HER LAST CHEMOTHERAPY WAS 6DAYS AGO. PT WAS DOING WELL UNTIL YESTERDAY C/O FEELING WEAK WITH NO APPETITE AND DEVELOPED THE SHAKING CHILLS AND A FEVER TO 103.9. PT ALSO STATED THAT HER MENTAL STATUS WAS SOMEWHAT CLOUDED AND THAT SHE HAD DECREASED URINE OUTPUT. SHE ALSO DEVELOPED PAIN AND EDEMA OF HER LABIA.\nSHE PRESENTED TO THE ED WITH TACHYCARDIA AND TEMP AND WAS STARTED ON CEFEPIME, VANCO AND CLINDA. SHE ALSO RECEIVED A TOTAL OF 4LNS AND A UNIT OF PRBC'S FOR A HCT OF 25.3. PT ALSO GIVEN TYLENOL X 2 FOR TEMP AND PRESENTLY IS 101.6.\nHR IN THE ED 130'S UP TO 150'S. HR TRENDED DOWN WITH FLUID AND AFTER TYLENOL WHICH BROUGHT HER FEVER DOWN.\nPT IS ON NEUTROPENIC PRECAUTIONS FOR WBC OF .5.\nPT IS RECEIVING THE LAST OF HER FLUID BOLUSES FOR A TOTAL OF 5LITERS.\nCV: HR NOW DOWN TO 108 NSR WITHOUT ECTOPY. BP WITHIN NORMAL LIMITS.\nTEMP 101.6. RESP RATE IN THE 20'S.\n\nRESP: PT IS ON RA WITH GOOD O2 SAT'S, LUNG SOUNDS CLEAR, NO SOB.\n\nGI: PT WILL BE NPO TILL FURTHER NOTICE, ABD SOFT NONTENDER WITH GOOD BOWEL SOUNDS. NO STOOL AT THIS TIME.\n\nGU: PT HAS NO DIFF VOIDING, AND GET OOB TO COMMODE.\n\nSKIN: PT HAS A CELLULITIC LOOKING AREA ON LEFT LABIA AND UPPER LEFT THIGH WHICH HAS BEEN CIRCLED WITH MARKER IN THE ED. SURGERY HAS BEEN CONSULTED TO EVALUATE. PT'S LACTATE 3.7. WILL FOLLOW. NEED SURGICAL INTERVENTION. DO NOT FEEL IT IS FASCIATIS.\n\nACCESS: PT HAS 1 #18 PERIPH IV AND LSC PORTA CATH. IV FLUID INF VIA PORTA CATH.\n\nSOCIAL: PT IS MARRIED AND HUSBAND IS HERE WITH HER. BOTH HAVE BEEN UPDATED BY THE .\n" }, { "category": "Nursing/other", "chartdate": "2176-05-10 00:00:00.000", "description": "Report", "row_id": 1543942, "text": "NPN 7a-7p\nPt. with mantle cell lymphoma admitted with fever and neutropenia.\n\nID: Tmax 103. Possible source cellulitic labia and 1 positive blood cx today-gram neg. rods. Surgery attempted to I & D area on labia that looked like a possible abscess but there was no drainage. Area of redness marked. Has increased since yesterday. Per surgery we are to evaluate q shift and mark area if there are changes. Plan for now it to continue antibiotics and use of peri bottle (per GYN). Gentamycin started today. Given 1x dose of 160mg and then standing order started. Should check peak and trough after 3rd dose of 120mg.\nWBC 0.1 this am. Repeat CBC pnd. at 5:30. To start meropenem today, remains on clinda and vanco. Also on nupogen per chemo protocol.\n\nCV: HR 104-120 sinus tach. no ectopy. K being repleted with K phos infusing over 6 hours. Writted for repeat lytes at 8pm-would hold off until all K phos infused which should be around 8:30 pm. Mg repleted.\n\nResp: Breath sounds clear bilaterally. 02 sats 96-99%. Does become dyspnic getting oob to commode.\n\nGI: Having some diarrhea (2x) -stool for c-diff sent. Pt. states diarrhea started after IV antibiotics. No appetite-can have neutropenic diet.\n\nGU: oob to commode with 1 assist.\n\nSocial: Husband in visiting most of day.\n\nA/P\n-continue antiobiotics\n-no need for any further surgical intervention at this point\n-continue neutropenic precautions\n-repeat labs this evening.\n" }, { "category": "Radiology", "chartdate": "2176-05-13 00:00:00.000", "description": "MRI PELVIS W/O & W/CONTRAST", "row_id": 863089, "text": " 11:14 AM\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR RECONSTRUCTION IMAGING\n Reason: pls evaluate for fasciitis, collection, or abscess in area o\n Admitting Diagnosis: LYMPHOMA;FEBRILE NEUTROPENIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with mantle cell lymphoma, now with severe vulvitis.\n REASON FOR THIS EXAMINATION:\n pls evaluate for fasciitis, collection, or abscess in area of mainly R sided\n vulvitis.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Mantle cell lymphoma. Now with severe vulvitis. Evaluate for\n fasciitis, or abscess.\n\n COMPARISON: CT , and .\n\n TECHNIQUE: Multiplanar MRI of the pelvis including T1W in-and-out-of-phase,\n HASTE, high resolution T2W fat sat, and 3D dynamic T1W fat sat imaging\n sequences without and with IV gadolinium contrast. Subtracted, multiplanar,\n and MIP reformatted images were generated on an external workstation.\n\n FINDINGS: There is edema within the asymmetrically enlarged right labia\n majora. The medial aspect of the right labia is thickened. There is no focal\n fluid collection or extension of the process into the deeper fascial planes of\n the muscles about the pelvis. There is superficial subcutaneous edema\n predominantly within the anterior aspect of both thighs. There is a small\n amount of free fluid within the deep pelvis. Bilateral iliac lymphadenopathy\n is present, left greater than the right, with left iliac nodes measuring up to\n 12 mm in maximum short axis dimension. Small bilateral inguinal lymph nodes\n are also present. There is heterogeneous bone marrow signal within the\n visualized aspect of both proximal femurs. The bladder is unremarkable.\n\n Multiplanar and MIP reformatted images were essential for evaluating the\n pelvis.\n\n IMPRESSION:\n 1. Asymmetric enlargement of the right labia majora, with edema and\n asymmetric thickening of the medial aspect of the right labia. This may be\n secondary to an infectious or inflammatory process, but direct involvement by\n lymphoma should be considered.\n 2. No evidence of abscess or fasciitis.\n 3. Superficial subcutaneous edema involving the anterior aspect of both\n thighs.\n 4. Bilateral iliac lymphadenopathy, left greater than the right.\n 5. Heterogeneous bone marrow signal within the proximal portions of both\n proximal femurs, likely related to the patient's history of lymphoma.\n 6. Small free fluid in the pelvis.\n\n KEYWORD: PELVIS\n (Over)\n\n 11:14 AM\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR RECONSTRUCTION IMAGING\n Reason: pls evaluate for fasciitis, collection, or abscess in area o\n Admitting Diagnosis: LYMPHOMA;FEBRILE NEUTROPENIA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2176-05-10 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 862725, "text": " 2:26 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: assess for gas-necrotizing facscitis\n Admitting Diagnosis: LYMPHOMA;FEBRILE NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with rapidly progressing cellulits\n REASON FOR THIS EXAMINATION:\n assess for gas-necrotizing facscitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rapidly progressing cellulitis. Assess for subcutaneous\n emphysema.\n\n 2 PORTABLE PELVIC RADIOGRAPHS. No prior studies available for comparison.\n Osseous structures of the pelvis appear intact. No definite subcutaneous\n emphysema is visualized. Note is made of asymmetrically enlarged soft tissues\n in the right vulvar region.\n\n" }, { "category": "Radiology", "chartdate": "2176-05-10 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 862726, "text": " 2:52 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: please do I minus scan of lower pelvis to examine for air in\n Admitting Diagnosis: LYMPHOMA;FEBRILE NEUTROPENIA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with ? nec fasc along labia majora.\n REASON FOR THIS EXAMINATION:\n please do I minus scan of lower pelvis to examine for air in labial area.\n CONTRAINDICATIONS for IV CONTRAST:\n cr\n ______________________________________________________________________________\n WET READ: MMBn FRI 4:57 AM\n No sign of nec fasc. Vulvitis of left labia majora and clitoris. No\n osteomyelitis of the pubic symphysis.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 63-year-old female with questionable necrotizing fasciitis on\n labia majora. Evaluate.\n\n COMPARISON: None.\n\n TECHNIQUE: Multidetector imaging was obtained from the lung bases through\n bilateral mid thighs without intravenous contrast. Coronal and sagittal\n reformatted images were obtained.\n\n CT ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST, WITHOUT ORAL CONTRAST:\n Focal 2 mm nodule is seen within the right lung base. Remainder of bilateral\n lung bases are clear. Imaging through the abdomen is limited by the lack of\n oral and intravenous contrast. Allowing for this, there is a small hiatal\n hernia and evidence of anemia. The liver is normal in attenuation without\n nodules or masses. Patient is status post cholecystectomy. The pancreas,\n spleen, bilateral adrenals, and both kidneys are normal. There is no\n hydronephrosis. The intraabdominal loops of large and small bowel are normal\n in caliber and contour. There is no mesenteric or retroperitoneal\n lymphadenopathy. There is no free air and no free fluid. There are focal\n calcifications of the vasculature.\n\n CT OF PELVIS WITHOUT ORAL, WITHOUT INTRAVENOUS CONTRAST: The bladder,\n sigmoid, rectum are normal. There is an increase in the soft tissue stranding\n descending below the pelvis, and surrounding the right labia majora.\n Additional dense attenuation of the clitoris is seen. The surrounding fat\n planes are preserved, and there is no stranding of the right adductor fascia.\n There are no focal fluid collections, evidence of air, or abscesses.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous\n abnormalities. There is no hypodensity within the pubic rami.\n\n Coronal and sagittal reformatted images confirm the axial findings. MPR value\n grade 3.\n\n (Over)\n\n 2:52 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: please do I minus scan of lower pelvis to examine for air in\n Admitting Diagnosis: LYMPHOMA;FEBRILE NEUTROPENIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n IMPRESSION: Vulvitis of the right labia majora, with involvement of the\n clitoris. No focal gas collections to suggest the presence of necrotizing\n fasciitis. The right adductor fascia is preserved. No radiographic evidence\n of osteomyelitis within the pubic symphysis.\n\n" }, { "category": "Radiology", "chartdate": "2176-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862721, "text": " 11:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: FEVER\n Admitting Diagnosis: LYMPHOMA;FEBRILE NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with fever and neutropenia\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with fever and neutropenia.\n\n COMPARISON: .\n\n SINGLE UPRIGHT PORTABLE AP VIEW OF THE CHEST: The lungs are clear. Cardiac,\n mediastinal, and hilar contours are within normal limits. Again seen is a\n left-sided central venous line with its tip in the superior vena cava.\n Otherwise, surrounding soft tissues and osseous structures are within normal\n limits.\n\n IMPRESSION: No acute cardiopulmonary process is identified.\n\n\n" }, { "category": "ECG", "chartdate": "2176-05-09 00:00:00.000", "description": "Report", "row_id": 185020, "text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing, sinus tachycardia noted\n\n" } ]

[ { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 614570, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo female with IVDA admitted to OSH 10 days ago initially with back\n pain and splenic hematoma. Went into multiorgan failure with septic\n shock, shock liver, coagulopathy, thrombocytoepnia, acute renal failure\n and acute respiratory failure. Echo demonstrated endocarditis of MV, AV\n and TR with wide open AI- started on broad spectrum abx with no\n organisms recovered. Initially on high doses of pressors, eventually\n weaned. Multiple digit ischemia from septic emboli vs pressors\n On , due to concern of ischemia with lactate of 15 , fluid\n collection on abd CT she went to the OR for ex lap. Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed.\n BRBPR in past 24 hour- has required 8 units blood, 2 6 packs of plts, 5\n units ffp, 1 unit cryo\n Bronch'd with white plaques seen endobronchially concerning for \n vs HSV- started empirically on Acylovir/diflucan afterwards\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n On transfer: vanc, imipenem, acyclovir, diflucan, lasix 80 mg ,\n hydrocortisone 25 mg IV Q8, fentanyl gtt, PPI, combivent\n Past medical history:\n Family history:\n Social History:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Multiple family members with IVDA\n Unable to obtain ROS from pt\n Occupation:\n Drugs: yes\n Tobacco: 1/2ppd\n Alcohol: no\n Other:\n Review of systems:\n Flowsheet Data as of 01:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 110 (110 - 114) bpm\n BP: 132/41(76) {132/34(72) - 161/56(152)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 193 mL\n PO:\n TF:\n IVF:\n 193 mL\n Blood products:\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 113 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 93%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, sclera icterus\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), scattered rhonchi\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, Obese, midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Musculoskeletal: Unable to stand\n Skin: Not assessed, No(t) Rash: , scattered dark lesions\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed, coughs, grimaces to suction\n Labs / Radiology\n 34.8\n 226 mg/dL\n 1.6\n 79\n 31\n 109\n 3.1 mEq/L\n 151\n [image002.jpg]\n 09:54 PM\n WBC\n 20\n Hct\n 34.8\n Plt\n 13-->105-->80\n TC02\n 32\n Glucose\n 226\n Other labs: PT / PTT / INR://2.1, ALT / AST:/ (peak 4000-8000),\n Differential-Neuts:85, Band:1, Fibrinogen:107 (less than assay at OSH),\n Lactic Acid:3.2 mmol/L\n Imaging: Outside Echo: AV destroyed, large vegetation on MV with severe\n MR, probable vegetation on TC\n MRI L-spine- read as blur artifact (?possible OM, our radioogy read)\n Abd/pelvic CT , - fluid collection in RLQ 3.3 cm? right\n hydrosalpinx ; 10 x 9.2 cm fluid collection in spleen, free fluid in\n pelvis,\n Head CT : no acute intracranial process\n CXR: cardiomegaly, atelectasis at right base\n Microbiology: Blood cultures , , - all NGTD\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis\n 1. Septic shock: hemodynamics improving, off pressors\n Continue antibiotics with vanco (dose by levels); cefipime for possible\n VAP\n Repeat echo\n Recheck Echo's, cultures\n ID consult\n Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n 2. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, none since\n Correct coagulopathy if recurrent bleeding (INR<1.5, plts>50)\n GI and Surgery involved\n 3. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings\n Wean FiO2 as tolerated, keep on AC.\n 4. Altered mental status- could be partly from sedative, need to also\n be concerned about embolic CVA- will obtain head CT, limit sedating\n meds\n 5. Coagulopathy/DIC + sepsis.\n 6. ARF- Cr 1.6 presumably due to ATN/sepsis. Will check U/A, urine\n 'lytes, avoid nephrotoxins\n 7. Hypernatremia: will correct with free water\n 8. NSTEMI: secondary to demand\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 614571, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo female with IVDA admitted to OSH 10 days ago initially with back\n pain and splenic hematoma. Went into multiorgan failure with septic\n shock, shock liver, coagulopathy, thrombocytoepnia, acute renal failure\n and acute respiratory failure. Echo demonstrated endocarditis of MV, AV\n and TR with wide open AI- started on broad spectrum abx with no\n organisms recovered. Initially on high doses of pressors, eventually\n weaned. Multiple digit ischemia from septic emboli vs pressors\n On , due to concern of ischemia with lactate of 15 , fluid\n collection on abd CT she went to the OR for ex lap. Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed.\n BRBPR in past 24 hour- has required 8 units blood, 2 6 packs of plts, 5\n units ffp, 1 unit cryo\n Bronch'd with white plaques seen endobronchially concerning for \n vs HSV- started empirically on Acylovir/diflucan afterwards\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n On transfer: vanc, imipenem, acyclovir, diflucan, lasix 80 mg ,\n hydrocortisone 25 mg IV Q8, fentanyl gtt, PPI, combivent\n Past medical history:\n Family history:\n Social History:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Multiple family members with IVDA\n Unable to obtain ROS from pt\n Occupation:\n Drugs: yes\n Tobacco: 1/2ppd\n Alcohol: no\n Other:\n Review of systems:\n Flowsheet Data as of 01:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 110 (110 - 114) bpm\n BP: 132/41(76) {132/34(72) - 161/56(152)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 193 mL\n PO:\n TF:\n IVF:\n 193 mL\n Blood products:\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 113 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 93%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, sclera icterus\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), scattered rhonchi\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, Obese, midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Musculoskeletal: Unable to stand\n Skin: Not assessed, No(t) Rash: , scattered dark lesions\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed, coughs, grimaces to suction\n Labs / Radiology\n 34.8\n 226 mg/dL\n 1.6\n 79\n 31\n 109\n 3.1 mEq/L\n 151\n [image002.jpg]\n 09:54 PM\n WBC\n 20\n Hct\n 34.8\n Plt\n 13-->105-->80\n TC02\n 32\n Glucose\n 226\n Other labs: PT / PTT / INR://2.1, ALT / AST:/ (peak 4000-8000),\n Differential-Neuts:85, Band:1, Fibrinogen:107 (less than assay at OSH),\n Lactic Acid:3.2 mmol/L\n Imaging: Outside Echo: AV destroyed, large vegetation on MV with severe\n MR, probable vegetation on TC\n MRI L-spine- read as blur artifact (?possible OM, our radioogy read)\n Abd/pelvic CT , - fluid collection in RLQ 3.3 cm? right\n hydrosalpinx ; 10 x 9.2 cm fluid collection in spleen, free fluid in\n pelvis,\n Head CT : no acute intracranial process\n CXR: cardiomegaly, atelectasis at right base\n Microbiology: Blood cultures , , - all NGTD\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis\n 1. Septic shock: hemodynamics improving, off pressors\n Continue antibiotics with vanco (dose by levels); cefipime for possible\n VAP\n Repeat echo\n Recheck Echo's, cultures\n ID consult\n Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n 2. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, none since\n Correct coagulopathy if recurrent bleeding (INR<1.5, plts>50)\n GI and Surgery involved\n 3. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings\n Wean FiO2 as tolerated, keep on AC.\n 4. Altered mental status- could be partly from sedative, need to also\n be concerned about embolic CVA- will obtain head CT, limit sedating\n meds\n 5. Coagulopathy/DIC + sepsis.\n 6. ARF- Cr 1.6 presumably due to ATN/sepsis. Will check U/A, urine\n 'lytes, avoid nephrotoxins\n 7. Hypernatremia: will correct with free water\n 8. NSTEMI: secondary to demand\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 614572, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 35 yo female with IVDA admitted to OSH 10 days ago initially with back\n pain and splenic hematoma. Went into multiorgan failure with septic\n shock, shock liver, coagulopathy, thrombocytoepnia, acute renal failure\n and acute respiratory failure. Echo demonstrated endocarditis of MV, AV\n and TR with wide open AI- started on broad spectrum abx with no\n organisms recovered. Initially on high doses of pressors, eventually\n weaned. Multiple digit ischemia from septic emboli vs pressors\n On , due to concern of ischemia with lactate of 15 , fluid\n collection on abd CT she went to the OR for ex lap. Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed.\n BRBPR in past 24 hour- has required 8 units blood, 2 6 packs of plts, 5\n units ffp, 1 unit cryo\n Bronch'd with white plaques seen endobronchially concerning for \n vs HSV- started empirically on Acylovir/diflucan afterwards\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n On transfer: vanc, imipenem, acyclovir, diflucan, lasix 80 mg ,\n hydrocortisone 25 mg IV Q8, fentanyl gtt, PPI, combivent\n Past medical history:\n Family history:\n Social History:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Multiple family members with IVDA\n Unable to obtain ROS from pt\n Occupation:\n Drugs: yes\n Tobacco: 1/2ppd\n Alcohol: no\n Other:\n Review of systems:\n Flowsheet Data as of 01:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 110 (110 - 114) bpm\n BP: 132/41(76) {132/34(72) - 161/56(152)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 193 mL\n PO:\n TF:\n IVF:\n 193 mL\n Blood products:\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 113 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 93%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, sclera icterus\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), scattered rhonchi\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, Obese, midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Musculoskeletal: Unable to stand\n Skin: Not assessed, No(t) Rash: , scattered dark lesions\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed, coughs, grimaces to suction\n Labs / Radiology\n 34.8\n 226 mg/dL\n 1.6\n 79\n 31\n 109\n 3.1 mEq/L\n 151\n [image002.jpg]\n 09:54 PM\n WBC\n 20\n Hct\n 34.8\n Plt\n 13-->105-->80\n TC02\n 32\n Glucose\n 226\n Other labs: PT / PTT / INR://2.1, ALT / AST:/ (peak 4000-8000),\n Differential-Neuts:85, Band:1, Fibrinogen:107 (less than assay at OSH),\n Lactic Acid:3.2 mmol/L\n Imaging: Outside Echo: AV destroyed, large vegetation on MV with severe\n MR, probable vegetation on TC\n MRI L-spine- read as blur artifact (?possible OM, our radioogy read)\n Abd/pelvic CT , - fluid collection in RLQ 3.3 cm? right\n hydrosalpinx ; 10 x 9.2 cm fluid collection in spleen, free fluid in\n pelvis,\n Head CT : no acute intracranial process\n CXR: cardiomegaly, atelectasis at right base\n Microbiology: Blood cultures , , - all NGTD\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis\n 1. Septic shock: hemodynamics improving, off pressors\n Continue antibiotics with vanco (dose by levels); cefipime for possible\n VAP\n Repeat echo\n Recheck Echo's, cultures\n ID consult\n Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n 2. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, none since\n Correct coagulopathy if recurrent bleeding (INR<1.5, plts>50)\n GI and Surgery involved\n 3. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings\n Wean FiO2 as tolerated, keep on AC.\n 4. Altered mental status- could be partly from sedative, need to also\n be concerned about embolic CVA- will obtain head CT, limit sedating\n meds\n 5. Coagulopathy/DIC + sepsis.\n 6. ARF- Cr 1.6 presumably due to ATN/sepsis. Will check U/A, urine\n 'lytes, avoid nephrotoxins\n 7. Hypernatremia: will correct with free water\n 8. NSTEMI: secondary to demand\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 614573, "text": "Chief Complaint:\n HPI:\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 01:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 113 (110 - 114) bpm\n BP: 115/46(76) {111/34(72) - 161/56(152)} mmHg\n RR: 24 (17 - 24) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 626 mL\n PO:\n TF:\n IVF:\n 370 mL\n Blood products:\n 257 mL\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 546 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 95%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 mg/dL\n 3.1 mEq/L\n [image002.jpg]\n \n 2:33 A1/10/ 09:54 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 32\n Glucose\n 226\n Other labs: Lactic Acid:3.2 mmol/L\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 614611, "text": "Chief Complaint:\n Chief Complaint: LUQ pain\n Reason for MICU admission/OSH transfer: septic shock, respiratory\n failure, further management of endocarditis and complications of septic\n shock\n HPI:\n 35F with history of IVDU, initially admitted to OSH on , now\n transferred to MICU for further management of her septic shock,\n endocarditis, and GI bleeding.\n .\n She initially fell on or . With this fall started to\n develop LUQ and mid back pain. She apparently presented to OSH and had\n CTA for rule out PE. This was negative, but she was called back to the\n hospital when CT read to have possible splenic hematoma. She has since\n had a very complicated OSH course with diagnosis of 3 valve\n endocarditis, septic shock, and more recent GI bleeding.\n .\n OSH course:\n overnight - admitted. levofloxacin for ?. dilaudid. neurosurg\n consult for back pain. abd/pelvic CT and surgical consult.\n - MRI lumbar spine.\n - change levoflox to zosyn.\n - crashed and transfer to ICU. intubated. neo, vasopressin,\n and norepi started, 3 units PRBCs, 2 FFP, hydrocortisone. abd/pelvic\n CT. antibiotics - vanco, clinda, zosyn. blood cultures drawn first on\n . TTE with endocarditis. WBCs 40K. L fem line placed. R fem\n Aline placed. Venous pH 6.87.\n - PICC line. 2 FFP, 1 6pk plts. then 4 FFP and 12pk plts preop.\n went to OR for exlap and bowel resection. lactate 14. peak LFTs (14K\n LDH, 9K AST, 3761 ALT).\n - 1 unit PRBCs. hematology consult, vascular consult.\n - bronch, started on IV acyclovir. HIT negative.\n - CT head. 1 6 pack platelets, 2 units PRBCs.\n - overnight transufused 1 or 2 units FFP, vit K, protonix. 4 more\n FFP and total 8 units PRBCs and 12 pack platelets, one unit cryo.\n .\n On the floor, patient arrives intubated and s/p few doses of fentanyl.\n Nonresponsive.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Medications on transfer:\n - Acyclovir 475 mg IV Q12 hours\n - Fluconazole 200 mg IV daily\n - Imipenem 500 mg IV Q12H\n - Vancomycin 1000 mg IV daily\n - Furosemide 80 mg IV BID\n - Hydrocortisone 25 mg IV Q8H\n - Fentanyl gtt\n - Insulin lispro per sliding scale\n - Pantoprazole 40 mg IV daily\n - Combivent 8 puffs Q4H\n .\n Medications at home:\n - Ibuprofen 800 mg Q5 hours prn\n - Diazepam 5 mg 1-2 tabs TID prn spasm\n - Naprosyn 500 mg Q12H prn\n - Percocet 1-2 tabs Q4-6H prn\n Past medical history:\n Family history:\n Social History:\n - Intravenous drug use - heroin, ?others\n - Lumbar disc disease with protrusion\n - Congenital single kidney\n IVDU in multiple family members per OSH notes\n - Tobacco: ~ PPD per patient at presentation.\n - Alcohol: Denied at presentation\n - Illicits: IVDU per family though patient initially denied this.\n Review of systems:\n Review of systems:\n (+) Per HPI\n (-) unable to obtain.\n Flowsheet Data as of 01:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 113 (110 - 114) bpm\n BP: 115/46(76) {111/34(72) - 161/56(152)} mmHg\n RR: 24 (17 - 24) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 626 mL\n PO:\n TF:\n IVF:\n 370 mL\n Blood products:\n 257 mL\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 546 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 95%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General: Intubated, nonresponsive to voice, occ cough and ?grimace, but\n otherwise nonresponsive to painful stimuli. Jaundiced.\n HEENT: Very icteric sclera, pupils minimally responsive but equal, ETT\n and OGT in place without obvious OP lesions. Fair dentition.\n Neck: supple, JVD difficult to appreciate with large neck, no LAD.\n Lungs: Clear to auscultation bilaterally, no wheezes, rales; occasional\n rhonchi R>L\n CV: Tachy, regular, S1 + S2, SM at apex, ?diastolic murmur at RSUB.\n Abdomen: no apparent bowel sounds. midline incision C/D/I, no\n drainage or bleeding, abdomen generally soft, appears non-tender,\n non-distended, no organomegaly.\n Rectal: bright red blood with some darker clots mixed with minimal\n stool.\n Ext: cool feet and fingers. Marked ischemic/necrotic changes of digits\n of UEs and LEs (L>>R of UEs, R>L of LEs). Palpable pulses of DPs and\n PTs, + LE pitting edema. Scattered large soft blisters over feet\n and lower legs. Scattered dark lesions peripherally ?emboli.\n Neuro: Nonresponsive as above. Not moving extremities. Tone normal.\n Labs / Radiology\n 151\n [image002.gif]\n 109\n [image002.gif]\n 79\n [image004.gif]\n 251\n AGap=14\n [image005.gif]\n 3.0\n [image002.gif]\n 31\n [image002.gif]\n 1.6\n [image007.gif]\n CK: 217\n MB: 3\n Trop-T: 0.34\n Ca: 7.4 Mg: 2.0 P: 5.0\n ALT: 113\n AP: 120\n Tbili: 16.6\n Alb: 2.5\n AST: 116\n LDH: 825\n Dbili: 13.0\n TProt:\n :\n Lip: 128\n TSH:Pnd\n Other Blood Chemistry:\n Vanco: 28.7\n 88\n 20.0\n [image007.gif]\n 12.6\n [image004.gif]\n 69\n [image008.gif]\n [image004.gif]\n 34.8\n [image007.gif]\n N:85 Band:1 L:7 M:3 E:0 Bas:0 Myelos: 3 Promyel: 1 Nrbc: 13\n Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: 1+ Target: OCCASIONAL Schisto: OCCASIONAL Burr: OCCASIONAL\n Plt-Est: Very Low\n PT: 22.4\n PTT: 29.7\n INR: 2.1\n Fibrinogen: 107\n \n 2:33 A1/10/ 09:54 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 32\n Glucose\n 226\n Other labs: Lactic Acid:3.2 mmol/L\n Last known OSH labs:\n WBC 20.6 (last man diff 75N, 13B, 9L, 2M, 1 meta)\n Hct 18.9 (1600 today); 25 (730 today)\n PRBCs at 2200 yest, 200, 400x2, 1000, 1200, 1740x2 (times).\n Plt 101 (1600 today); 13 (730 today)\n INR 2 (1600) - s/p 5 FFP\n vanco 15 (1600 today)\n Na 147, K 3, Cl 106, bicarb 28, creat 1.8, BUN 78, iCa 0.92, Phos 5.3\n Tbili 14, AST 122, ALT 170, AP 133, albumin 2.1, LD 772, CK 182 MB 4\n lactate 4.7\n troponin I 5.6 (today)\n ABG 7.49/36/137 on AC 0.40, 650 x 10, PEEP 5\n HIT Ab : negative (though borderline)\n .\n Micro:\n MRSA nares : negative.\n sputum cx : no growth.\n blood cx : negative\n blood cx , , : NGTD\n BAL : AFB smear neg. culture neg.\n blister : negative.\n urine : negative.\n .\n Images:\n MRI L spine without contrast: limited by motion artifact. Possible R\n lateral disc herniation L4-5 with disc bulging and protrusion.\n .\n TTE : slight LV dilation, normal LV function EF 50-55%. RV\n systolic function mod-severely reduced, RVSP 43. Severe AI.\n Vegetation on aortic valve, prolapses into LVOT. MV mod thickened.\n can't exclude vegetation. ?perforated mitral leaflet. Severe MR.\n Echodensity in the RV appears attached to RV chordae. Mild-mod TR.\n .\n TEE : aortic valve cusps have been essentially destroyed. Large\n vegetation, prolapses into aortic root and into LVOT, severe AI.\n Apparent perforation of anterior mitral leaflet iwth ?vegetation and\n severe MR. TV appears intact. ?small vegetation vs. redudant chordae.\n moderate TR. No abscess seen.\n .\n CT abd/pelvis : large multi locular lesion in spleen 10x0.6x0.8.\n 14 mm round low denisty L adrenal mass. Trace free fluid in pelvis.\n Small to mod bilateral effusions.\n .\n CT abd/pelvis : new decreased enhancement throughout liver -\n ?acute hepatic failure. edema surrounding proximal pancreas.\n Increased free fluid in Abd/pelvis, appears simple. splenic lesion\n unchanged (dictated at 10 x 9.2). increased wall thickening in small\n bowel and colon. appendix not seen. tubular fluid filled structure in\n RLQ measuring 3.3 cm - ?R hydrosalpinx.\n .\n CT head : presence of air fluid levels in paranasal sinuses.\n otherwise no intracranial process.\n .\n CXR : L sided PICC line, ET and OGT, midl central congestion, L\n hemidiaphragm obscured from atelectasis and/or infiltrate plus small\n effusion. Mild atelectasis and/or infiltrate at R base medially.\n .\n CXR (here): L sided PICC, ET and OGT all in good position.\n Cardiomegaly. R sided atelectasis. Bilateral R>L effusions.\n .\n Bronch report : moderate amount of blood in R and L mainstem\n bronchi, seemed to be coming from RLL and LLL. mucosa filled up with\n whitish thick plaques particularly at R mainstem bronchus (concern for\n herpetic infection).\n .\n EKG: sinus tach at 114, NANI, low voltage, poor RWP, nonspecific T wave\n flattening diffusely.\n Assessment and Plan\n 35F with IVDU, congenital single kidney, presenting to OSH s/p fall\n with subsequent development of septic shock, endocarditis, multiple\n sites of bleeding, now transfer to MICU for further management.\n .\n # Septic shock. BPs improving and off pressors now. Source thought to\n be endocarditis, ?other ongoing infection. Likely with multiple sites\n of embolic burden - splenic abscess, ?vertebral osteo per our\n radiologists, ?intraabdominal abscess collection (though per\n descriptions more c/w endometriosis).\n - CVL: Replace and maintain central access; d/c PICC.\n - Replace Aline and dc femoral Aline.\n - Pressors: norepi as first choice if needed.\n - Wean steroids to off.\n - Broad spectrum antibiotics with coverage as detailed below (vanco,\n cefepime, flagyl, acyclovir).\n - Source workup and control: TTE +/- TEE and cardiac surgery consult;\n CT abdomen when stable and general surgery consult; blood, urine,\n sputum, C.diff cultures; ?spine intervention.\n .\n # BRBPR/anemia. In last 24 hours has required 8 units PRBCs in\n addition to cryo, platelets, and FFP. Is POD 4 from ?partial cecectomy\n after concern for bowel ischemia at OSH. OGL negative and low\n suspicion for this being an upper source. No evidence of vaginal\n source on exam.\n - Surgery consult - ?post op bleeding source.\n - GI aware, will see in AM.\n - COnsider IR consult, though above services more likely to be helpful\n in this situation (tics less likely).\n - Attempt to CT abdomen if stability allows.\n - Try to obtain more details regarding operative procedure.\n - Transfuse Hct < 30, sooner if bleeding.\n - Keep plts > 50K, INR < 2, f'gen >100.\n - Monitor calcium.\n - Consider ddAVP if uremia/ARF worsens.\n - IV PPI.\n - Maintain IV access: TLC vs. (more likely if evidence of\n significant ongoing bleeding).\n - Keep NPO.\n .\n # Respiratory failure. Intubated for unclear reasons at OSH, but\n remains intubated for multiple reasons (mental status in particular).\n With significant AI and MR, at risk of acute CHF once positive pressure\n removed.\n - Keep on current vent settings - AC including PEEP 8.\n - Replace Aline.\n - Keep off sedation and monitor respiratory status.\n - Check CT chest if going down for CT abdomen given R sided valvular\n disease to assess for septic emboli.\n .\n # Endocarditis. No organism ever isolated as above. Received\n levofloxacin and zosyn doses prior to blood cultures. 4 sets done at\n OSH all NGTD (on antibiotics). Known high vegetation burden with\n significant valvular compromise. No known abscesses.\n - Monitor for conduction disturbances on tele/ECG.\n - Repeat TTE and likely TEE here.\n - Can go through further detailed records re: ?any other abx before\n blood cultures drawn. Repeat cultures here.\n - Continue IV vanco; high risks of gent/AGs.\n - Cardiac surgery consult in AM.\n - ID consult in AM.\n .\n # Altered mental status. Unclear how much she was given for sedation\n at OSH, but not waking up here. Nonresponsive to painful stimuli of\n extremities, but does seem to react to suctioning. Was on fent gtt at\n OSH and got some fent boluses en route.\n - Hold sedating meds.\n - Repeat head CT with other scans and have our radiologists review OSH\n scan (?poor grey-white matter differentiation).\n .\n # ARF. No known baseline insufficiency. Likely ATN in setting of\n septic shock. Also consider AIN from meds, prerenal or ATN from other\n causes.\n - Renally dose meds.\n - Send urine lytes, eos.\n - CT abdomen will assess for hydro.\n - Renal consult if worsens; currently no indication for acute HD.\n .\n # Coagulopathy. Likely DIC plus some bone marrow suppression from\n severe sepsis, plus synthetic dysfunction in setting of shock liver.\n Heme had been following patient for low plts as well - per OSH heme, no\n schistocytes, and HIT AB negative. Will be difficult to tell\n morphologies on smear after so many blood products.\n - supportive care for now - goal plts > 50, INR > 2, fibrinogen > 100.\n - ?heme onc input here, though OSH did not think TTP to be likely.\n .\n # Hyperbilirubinemia/transaminitis. History of shock liver from\n profound hypotension at OSH. Transaminases improved overall, unclear\n on bilirubin trend. Presumably direct in setting of shock liver, vs.\n indirect if more hemolysis related.\n - Maintain normotensive state.\n - Check direct bili.\n - Avoid hepatic toxins.\n - COntinue to monitor.\n .\n # Leukocytosis. With ongoing infections as above.\n - Empiric C.diff coverage with IV flagyl for now; send C.diff.\n - Other antibiotics as above.\n .\n # ?tracheal HSV. Started on acyclovir following findings of lesions on\n bronch. ?HSV tracheobronchitis +/- pneumonitis. Did not appear to\n send BAL fluid for viral culture. Not known immunocompromised host -\n ?reason for this infection. Definitely with HIV risk factors.\n - Verify negative UPT.\n - Attempt to check HIV status, as would seemingly change management.\n - IV acyclovir at 5 mg/kg Q12H given renal function; though treatment\n with acyclovir in BAL positive ICU patients has not been shown to\n improve outcomes. Low threshold to hold off.\n - Re-bronch tomorrow, send BAL fluid.\n .\n # Necrotic digits. Appearance seems more consistent with necrosis \n pressors, vs. septic emboli. No reason to suspect plain clot as\n emboli, nor acute arterial thrombosis. Great pulses.\n - Maintain off pressors as possible.\n - Management of endocarditis as above.\n - Consider vascular input (more for managment of necrotic digits,\n ?amputation vs. observation). No evidence of current infection.\n .\n # Splenic abscess. Collection stable on imaging at OSH. In this\n clinical context, thought to be abscess more likely than hematoma.\n - CT abd/pelvis now.\n - Surgical consult, if any management appropriate. ?IR input re:\n drainage. COntinue antibiotics.\n .\n # ?Vertebral osteomyelitis. OSH read of MRI benign (though limited),\n some question of osteo by our radiologists on very prelim read.\n - Formal read by our radiologists; consider spine input.\n .\n # NSTEMI. Likely demand in setting of all the above.\n - Trend enzymes.\n - Cannot anticoagulate or give ASA in setting of this bleed. Unclear\n that these would be beneficial with this pathophysiology in addition.\n .\n # Metabolic alkalosis. Has been getting diuresed at OSH; most likely\n contraction alkalosis.\n - Hold lasix in setting of bleed.\n .\n # Hypernatremia. Iatrogenic likely with multiple meds.\n - Replete free water IV as NPO currently.\n .\n # FEN: NPO, IV electrolyte repletion. Glucose control with SSI, low\n threshold to gtt.\n # Prophylaxis: Hold HSQ with low plts, boots, PPI.\n # Access: L PICC needs replacing, R fem line needs replacing.\n # Communication: Patient, family\n # Code: Full\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: NPO, replete lytes\n Glycemic Control: ISS, gtt if needed\n Lines:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 614719, "text": "Chief Complaint:\n Chief Complaint: LUQ pain\n Reason for MICU admission/OSH transfer: septic shock, respiratory\n failure, further management of endocarditis and complications of septic\n shock\n HPI:\n 35F with history of IVDU, initially admitted to OSH on , now\n transferred to MICU for further management of her septic shock,\n endocarditis, and GI bleeding.\n .\n She initially fell on or . With this fall started to\n develop LUQ and mid back pain. She apparently presented to OSH and had\n CTA for rule out PE. This was negative, but she was called back to the\n hospital when CT read to have possible splenic hematoma. She has since\n had a very complicated OSH course with diagnosis of 3 valve\n endocarditis, septic shock, and more recent GI bleeding.\n .\n OSH course:\n overnight - admitted. levofloxacin for ?. dilaudid. neurosurg\n consult for back pain. abd/pelvic CT and surgical consult.\n - MRI lumbar spine.\n - change levoflox to zosyn.\n - crashed and transfer to ICU. intubated. neo, vasopressin,\n and norepi started, 3 units PRBCs, 2 FFP, hydrocortisone. abd/pelvic\n CT. antibiotics - vanco, clinda, zosyn. blood cultures drawn first on\n . TTE with endocarditis. WBCs 40K. L fem line placed. R fem\n Aline placed. Venous pH 6.87.\n - PICC line. 2 FFP, 1 6pk plts. then 4 FFP and 12pk plts preop.\n went to OR for exlap and bowel resection. lactate 14. peak LFTs (14K\n LDH, 9K AST, 3761 ALT).\n - 1 unit PRBCs. hematology consult, vascular consult.\n - bronch, started on IV acyclovir. HIT negative.\n - CT head. 1 6 pack platelets, 2 units PRBCs.\n - overnight transufused 1 or 2 units FFP, vit K, protonix. 4 more\n FFP and total 8 units PRBCs and 12 pack platelets, one unit cryo.\n .\n On the floor, patient arrives intubated and s/p few doses of fentanyl.\n Nonresponsive.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Medications on transfer:\n - Acyclovir 475 mg IV Q12 hours\n - Fluconazole 200 mg IV daily\n - Imipenem 500 mg IV Q12H\n - Vancomycin 1000 mg IV daily\n - Furosemide 80 mg IV BID\n - Hydrocortisone 25 mg IV Q8H\n - Fentanyl gtt\n - Insulin lispro per sliding scale\n - Pantoprazole 40 mg IV daily\n - Combivent 8 puffs Q4H\n .\n Medications at home:\n - Ibuprofen 800 mg Q5 hours prn\n - Diazepam 5 mg 1-2 tabs TID prn spasm\n - Naprosyn 500 mg Q12H prn\n - Percocet 1-2 tabs Q4-6H prn\n Past medical history:\n Family history:\n Social History:\n - Intravenous drug use - heroin, ?others\n - Lumbar disc disease with protrusion\n - Congenital single kidney\n IVDU in multiple family members per OSH notes\n - Tobacco: ~ PPD per patient at presentation.\n - Alcohol: Denied at presentation\n - Illicits: IVDU per family though patient initially denied this.\n Review of systems:\n Review of systems:\n (+) Per HPI\n (-) unable to obtain.\n Flowsheet Data as of 01:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 113 (110 - 114) bpm\n BP: 115/46(76) {111/34(72) - 161/56(152)} mmHg\n RR: 24 (17 - 24) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 626 mL\n PO:\n TF:\n IVF:\n 370 mL\n Blood products:\n 257 mL\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 546 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 95%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General: Intubated, nonresponsive to voice, occ cough and ?grimace, but\n otherwise nonresponsive to painful stimuli. Jaundiced.\n HEENT: Very icteric sclera, pupils minimally responsive but equal, ETT\n and OGT in place without obvious OP lesions. Fair dentition.\n Neck: supple, JVD difficult to appreciate with large neck, no LAD.\n Lungs: Clear to auscultation bilaterally, no wheezes, rales; occasional\n rhonchi R>L\n CV: Tachy, regular, S1 + S2, SM at apex, ?diastolic murmur at RSUB.\n Abdomen: no apparent bowel sounds. midline incision C/D/I, no\n drainage or bleeding, abdomen generally soft, appears non-tender,\n non-distended, no organomegaly.\n Rectal: bright red blood with some darker clots mixed with minimal\n stool.\n Ext: cool feet and fingers. Marked ischemic/necrotic changes of digits\n of UEs and LEs (L>>R of UEs, R>L of LEs). Palpable pulses of DPs and\n PTs, + LE pitting edema. Scattered large soft blisters over feet\n and lower legs. Scattered dark lesions peripherally ?emboli.\n Neuro: Nonresponsive as above. Not moving extremities. Tone normal.\n Labs / Radiology\n 151\n [image002.gif]\n 109\n [image002.gif]\n 79\n [image004.gif]\n 251\n AGap=14\n [image005.gif]\n 3.0\n [image002.gif]\n 31\n [image002.gif]\n 1.6\n [image007.gif]\n CK: 217\n MB: 3\n Trop-T: 0.34\n Ca: 7.4 Mg: 2.0 P: 5.0\n ALT: 113\n AP: 120\n Tbili: 16.6\n Alb: 2.5\n AST: 116\n LDH: 825\n Dbili: 13.0\n TProt:\n :\n Lip: 128\n TSH:Pnd\n Other Blood Chemistry:\n Vanco: 28.7\n 88\n 20.0\n [image007.gif]\n 12.6\n [image004.gif]\n 69\n [image008.gif]\n [image004.gif]\n 34.8\n [image007.gif]\n N:85 Band:1 L:7 M:3 E:0 Bas:0 Myelos: 3 Promyel: 1 Nrbc: 13\n Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: 1+ Target: OCCASIONAL Schisto: OCCASIONAL Burr: OCCASIONAL\n Plt-Est: Very Low\n PT: 22.4\n PTT: 29.7\n INR: 2.1\n Fibrinogen: 107\n \n 2:33 A1/10/ 09:54 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 32\n Glucose\n 226\n Other labs: Lactic Acid:3.2 mmol/L\n Last known OSH labs:\n WBC 20.6 (last man diff 75N, 13B, 9L, 2M, 1 meta)\n Hct 18.9 (1600 today); 25 (730 today)\n PRBCs at 2200 yest, 200, 400x2, 1000, 1200, 1740x2 (times).\n Plt 101 (1600 today); 13 (730 today)\n INR 2 (1600) - s/p 5 FFP\n vanco 15 (1600 today)\n Na 147, K 3, Cl 106, bicarb 28, creat 1.8, BUN 78, iCa 0.92, Phos 5.3\n Tbili 14, AST 122, ALT 170, AP 133, albumin 2.1, LD 772, CK 182 MB 4\n lactate 4.7\n troponin I 5.6 (today)\n ABG 7.49/36/137 on AC 0.40, 650 x 10, PEEP 5\n HIT Ab : negative (though borderline)\n .\n Micro:\n MRSA nares : negative.\n sputum cx : no growth.\n blood cx : negative\n blood cx , , : NGTD\n BAL : AFB smear neg. culture neg.\n blister : negative.\n urine : negative.\n .\n Images:\n MRI L spine without contrast: limited by motion artifact. Possible R\n lateral disc herniation L4-5 with disc bulging and protrusion.\n .\n TTE : slight LV dilation, normal LV function EF 50-55%. RV\n systolic function mod-severely reduced, RVSP 43. Severe AI.\n Vegetation on aortic valve, prolapses into LVOT. MV mod thickened.\n can't exclude vegetation. ?perforated mitral leaflet. Severe MR.\n Echodensity in the RV appears attached to RV chordae. Mild-mod TR.\n .\n TEE : aortic valve cusps have been essentially destroyed. Large\n vegetation, prolapses into aortic root and into LVOT, severe AI.\n Apparent perforation of anterior mitral leaflet iwth ?vegetation and\n severe MR. TV appears intact. ?small vegetation vs. redudant chordae.\n moderate TR. No abscess seen.\n .\n CT abd/pelvis : large multi locular lesion in spleen 10x0.6x0.8.\n 14 mm round low denisty L adrenal mass. Trace free fluid in pelvis.\n Small to mod bilateral effusions.\n .\n CT abd/pelvis : new decreased enhancement throughout liver -\n ?acute hepatic failure. edema surrounding proximal pancreas.\n Increased free fluid in Abd/pelvis, appears simple. splenic lesion\n unchanged (dictated at 10 x 9.2). increased wall thickening in small\n bowel and colon. appendix not seen. tubular fluid filled structure in\n RLQ measuring 3.3 cm - ?R hydrosalpinx.\n .\n CT head : presence of air fluid levels in paranasal sinuses.\n otherwise no intracranial process.\n .\n CXR : L sided PICC line, ET and OGT, midl central congestion, L\n hemidiaphragm obscured from atelectasis and/or infiltrate plus small\n effusion. Mild atelectasis and/or infiltrate at R base medially.\n .\n CXR (here): L sided PICC, ET and OGT all in good position.\n Cardiomegaly. R sided atelectasis. Bilateral R>L effusions.\n .\n Bronch report : moderate amount of blood in R and L mainstem\n bronchi, seemed to be coming from RLL and LLL. mucosa filled up with\n whitish thick plaques particularly at R mainstem bronchus (concern for\n herpetic infection).\n .\n EKG: sinus tach at 114, NANI, low voltage, poor RWP, nonspecific T wave\n flattening diffusely.\n Assessment and Plan\n 35F with IVDU, congenital single kidney, presenting to OSH s/p fall\n with subsequent development of septic shock, endocarditis, multiple\n sites of bleeding, now transfer to MICU for further management.\n .\n # Septic shock. BPs improving and off pressors now. Source thought to\n be endocarditis, ?other ongoing infection. Likely with multiple sites\n of embolic burden - splenic abscess, ?vertebral osteo per our\n radiologists, ?intraabdominal abscess collection (though per\n descriptions more c/w endometriosis).\n - CVL: Replace and maintain central access; d/c PICC.\n - Replace Aline and dc femoral Aline.\n - Pressors: norepi as first choice if needed.\n - Wean steroids to off.\n - Broad spectrum antibiotics with coverage as detailed below (vanco,\n cefepime, flagyl, acyclovir).\n - Source workup and control: TTE +/- TEE and cardiac surgery consult;\n CT abdomen when stable and general surgery consult; blood, urine,\n sputum, C.diff cultures; ?spine intervention.\n .\n # BRBPR/anemia. In last 24 hours has required 8 units PRBCs in\n addition to cryo, platelets, and FFP. Is POD 4 from ?partial cecectomy\n after concern for bowel ischemia at OSH. OGL negative and low\n suspicion for this being an upper source. No evidence of vaginal\n source on exam.\n - Surgery consult - ?post op bleeding source.\n - GI aware, will see in AM.\n - COnsider IR consult, though above services more likely to be helpful\n in this situation (tics less likely).\n - Attempt to CT abdomen if stability allows.\n - Try to obtain more details regarding operative procedure.\n - Transfuse Hct < 30, sooner if bleeding.\n - Keep plts > 50K, INR < 2, f'gen >100.\n - Monitor calcium.\n - Consider ddAVP if uremia/ARF worsens.\n - IV PPI.\n - Maintain IV access: TLC vs. (more likely if evidence of\n significant ongoing bleeding).\n - Keep NPO.\n .\n # Respiratory failure. Intubated for unclear reasons at OSH, but\n remains intubated for multiple reasons (mental status in particular).\n With significant AI and MR, at risk of acute CHF once positive pressure\n removed.\n - Keep on current vent settings - AC including PEEP 8.\n - Replace Aline.\n - Keep off sedation and monitor respiratory status.\n - Check CT chest if going down for CT abdomen given R sided valvular\n disease to assess for septic emboli.\n .\n # Endocarditis. No organism ever isolated as above. Received\n levofloxacin and zosyn doses prior to blood cultures. 4 sets done at\n OSH all NGTD (on antibiotics). Known high vegetation burden with\n significant valvular compromise. No known abscesses.\n - Monitor for conduction disturbances on tele/ECG.\n - Repeat TTE and likely TEE here.\n - Can go through further detailed records re: ?any other abx before\n blood cultures drawn. Repeat cultures here.\n - Continue IV vanco; high risks of gent/AGs.\n - Cardiac surgery consult in AM.\n - ID consult in AM.\n .\n # Altered mental status. Unclear how much she was given for sedation\n at OSH, but not waking up here. Nonresponsive to painful stimuli of\n extremities, but does seem to react to suctioning. Was on fent gtt at\n OSH and got some fent boluses en route.\n - Hold sedating meds.\n - Repeat head CT with other scans and have our radiologists review OSH\n scan (?poor grey-white matter differentiation).\n .\n # ARF. No known baseline insufficiency. Likely ATN in setting of\n septic shock. Also consider AIN from meds, prerenal or ATN from other\n causes.\n - Renally dose meds.\n - Send urine lytes, eos.\n - CT abdomen will assess for hydro.\n - Renal consult if worsens; currently no indication for acute HD.\n .\n # Coagulopathy. Likely DIC plus some bone marrow suppression from\n severe sepsis, plus synthetic dysfunction in setting of shock liver.\n Heme had been following patient for low plts as well - per OSH heme, no\n schistocytes, and HIT AB negative. Will be difficult to tell\n morphologies on smear after so many blood products.\n - supportive care for now - goal plts > 50, INR > 2, fibrinogen > 100.\n - ?heme onc input here, though OSH did not think TTP to be likely.\n .\n # Hyperbilirubinemia/transaminitis. History of shock liver from\n profound hypotension at OSH. Transaminases improved overall, unclear\n on bilirubin trend. Presumably direct in setting of shock liver, vs.\n indirect if more hemolysis related.\n - Maintain normotensive state.\n - Check direct bili.\n - Avoid hepatic toxins.\n - COntinue to monitor.\n .\n # Leukocytosis. With ongoing infections as above.\n - Empiric C.diff coverage with IV flagyl for now; send C.diff.\n - Other antibiotics as above.\n .\n # ?tracheal HSV. Started on acyclovir following findings of lesions on\n bronch. ?HSV tracheobronchitis +/- pneumonitis. Did not appear to\n send BAL fluid for viral culture. Not known immunocompromised host -\n ?reason for this infection. Definitely with HIV risk factors.\n - Verify negative UPT.\n - Attempt to check HIV status, as would seemingly change management.\n - IV acyclovir at 5 mg/kg Q12H given renal function; though treatment\n with acyclovir in BAL positive ICU patients has not been shown to\n improve outcomes. Low threshold to hold off.\n - Re-bronch tomorrow, send BAL fluid.\n .\n # Necrotic digits. Appearance seems more consistent with necrosis \n pressors, vs. septic emboli. No reason to suspect plain clot as\n emboli, nor acute arterial thrombosis. Great pulses.\n - Maintain off pressors as possible.\n - Management of endocarditis as above.\n - Consider vascular input (more for managment of necrotic digits,\n ?amputation vs. observation). No evidence of current infection.\n .\n # Splenic abscess. Collection stable on imaging at OSH. In this\n clinical context, thought to be abscess more likely than hematoma.\n - CT abd/pelvis now.\n - Surgical consult, if any management appropriate. ?IR input re:\n drainage. COntinue antibiotics.\n .\n # ?Vertebral osteomyelitis. OSH read of MRI benign (though limited),\n some question of osteo by our radiologists on very prelim read.\n - Formal read by our radiologists; consider spine input.\n .\n # NSTEMI. Likely demand in setting of all the above.\n - Trend enzymes.\n - Cannot anticoagulate or give ASA in setting of this bleed. Unclear\n that these would be beneficial with this pathophysiology in addition.\n .\n # Metabolic alkalosis. Has been getting diuresed at OSH; most likely\n contraction alkalosis.\n - Hold lasix in setting of bleed.\n .\n # Hypernatremia. Iatrogenic likely with multiple meds.\n - Replete free water IV as NPO currently.\n .\n # FEN: NPO, IV electrolyte repletion. Glucose control with SSI, low\n threshold to gtt.\n # Prophylaxis: Hold HSQ with low plts, boots, PPI.\n # Access: L PICC needs replacing, R fem line needs replacing.\n # Communication: Patient, family\n # Code: Full\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: NPO, replete lytes\n Glycemic Control: ISS, gtt if needed\n Lines:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 614720, "text": "Chief Complaint:\n Chief Complaint: LUQ pain\n Reason for MICU admission/OSH transfer: septic shock, respiratory\n failure, further management of endocarditis and complications of septic\n shock\n HPI:\n 35F with history of IVDU, initially admitted to OSH on , now\n transferred to MICU for further management of her septic shock,\n endocarditis, and GI bleeding.\n .\n She initially fell on or . With this fall started to\n develop LUQ and mid back pain. She apparently presented to OSH and had\n CTA for rule out PE. This was negative, but she was called back to the\n hospital when CT read to have possible splenic hematoma. She has since\n had a very complicated OSH course with diagnosis of 3 valve\n endocarditis, septic shock, and more recent GI bleeding.\n .\n OSH course:\n overnight - admitted. levofloxacin for ?. dilaudid. neurosurg\n consult for back pain. abd/pelvic CT and surgical consult.\n - MRI lumbar spine.\n - change levoflox to zosyn.\n - crashed and transfer to ICU. intubated. neo, vasopressin,\n and norepi started, 3 units PRBCs, 2 FFP, hydrocortisone. abd/pelvic\n CT. antibiotics - vanco, clinda, zosyn. blood cultures drawn first on\n . TTE with endocarditis. WBCs 40K. L fem line placed. R fem\n Aline placed. Venous pH 6.87.\n - PICC line. 2 FFP, 1 6pk plts. then 4 FFP and 12pk plts preop.\n went to OR for exlap and bowel resection. lactate 14. peak LFTs (14K\n LDH, 9K AST, 3761 ALT).\n - 1 unit PRBCs. hematology consult, vascular consult.\n - bronch, started on IV acyclovir. HIT negative.\n - CT head. 1 6 pack platelets, 2 units PRBCs.\n - overnight transufused 1 or 2 units FFP, vit K, protonix. 4 more\n FFP and total 8 units PRBCs and 12 pack platelets, one unit cryo.\n .\n On the floor, patient arrives intubated and s/p few doses of fentanyl.\n Nonresponsive.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Medications on transfer:\n - Acyclovir 475 mg IV Q12 hours\n - Fluconazole 200 mg IV daily\n - Imipenem 500 mg IV Q12H\n - Vancomycin 1000 mg IV daily\n - Furosemide 80 mg IV BID\n - Hydrocortisone 25 mg IV Q8H\n - Fentanyl gtt\n - Insulin lispro per sliding scale\n - Pantoprazole 40 mg IV daily\n - Combivent 8 puffs Q4H\n .\n Medications at home:\n - Ibuprofen 800 mg Q5 hours prn\n - Diazepam 5 mg 1-2 tabs TID prn spasm\n - Naprosyn 500 mg Q12H prn\n - Percocet 1-2 tabs Q4-6H prn\n Past medical history:\n Family history:\n Social History:\n - Intravenous drug use - heroin, ?others\n - Lumbar disc disease with protrusion\n - Congenital single kidney\n IVDU in multiple family members per OSH notes\n - Tobacco: ~ PPD per patient at presentation.\n - Alcohol: Denied at presentation\n - Illicits: IVDU per family though patient initially denied this.\n Review of systems:\n Review of systems:\n (+) Per HPI\n (-) unable to obtain.\n Flowsheet Data as of 01:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 113 (110 - 114) bpm\n BP: 115/46(76) {111/34(72) - 161/56(152)} mmHg\n RR: 24 (17 - 24) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 626 mL\n PO:\n TF:\n IVF:\n 370 mL\n Blood products:\n 257 mL\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 546 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 95%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General: Intubated, nonresponsive to voice, occ cough and ?grimace, but\n otherwise nonresponsive to painful stimuli. Jaundiced.\n HEENT: Very icteric sclera, pupils minimally responsive but equal, ETT\n and OGT in place without obvious OP lesions. Fair dentition.\n Neck: supple, JVD difficult to appreciate with large neck, no LAD.\n Lungs: Clear to auscultation bilaterally, no wheezes, rales; occasional\n rhonchi R>L\n CV: Tachy, regular, S1 + S2, SM at apex, ?diastolic murmur at RSUB.\n Abdomen: no apparent bowel sounds. midline incision C/D/I, no\n drainage or bleeding, abdomen generally soft, appears non-tender,\n non-distended, no organomegaly.\n Rectal: bright red blood with some darker clots mixed with minimal\n stool.\n Ext: cool feet and fingers. Marked ischemic/necrotic changes of digits\n of UEs and LEs (L>>R of UEs, R>L of LEs). Palpable pulses of DPs and\n PTs, + LE pitting edema. Scattered large soft blisters over feet\n and lower legs. Scattered dark lesions peripherally ?emboli.\n Neuro: Nonresponsive as above. Not moving extremities. Tone normal.\n Labs / Radiology\n 151\n [image002.gif]\n 109\n [image002.gif]\n 79\n [image004.gif]\n 251\n AGap=14\n [image005.gif]\n 3.0\n [image002.gif]\n 31\n [image002.gif]\n 1.6\n [image007.gif]\n CK: 217\n MB: 3\n Trop-T: 0.34\n Ca: 7.4 Mg: 2.0 P: 5.0\n ALT: 113\n AP: 120\n Tbili: 16.6\n Alb: 2.5\n AST: 116\n LDH: 825\n Dbili: 13.0\n TProt:\n :\n Lip: 128\n TSH:Pnd\n Other Blood Chemistry:\n Vanco: 28.7\n 88\n 20.0\n [image007.gif]\n 12.6\n [image004.gif]\n 69\n [image008.gif]\n [image004.gif]\n 34.8\n [image007.gif]\n N:85 Band:1 L:7 M:3 E:0 Bas:0 Myelos: 3 Promyel: 1 Nrbc: 13\n Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: 1+ Target: OCCASIONAL Schisto: OCCASIONAL Burr: OCCASIONAL\n Plt-Est: Very Low\n PT: 22.4\n PTT: 29.7\n INR: 2.1\n Fibrinogen: 107\n \n 2:33 A1/10/ 09:54 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 32\n Glucose\n 226\n Other labs: Lactic Acid:3.2 mmol/L\n Last known OSH labs:\n WBC 20.6 (last man diff 75N, 13B, 9L, 2M, 1 meta)\n Hct 18.9 (1600 today); 25 (730 today)\n PRBCs at 2200 yest, 200, 400x2, 1000, 1200, 1740x2 (times).\n Plt 101 (1600 today); 13 (730 today)\n INR 2 (1600) - s/p 5 FFP\n vanco 15 (1600 today)\n Na 147, K 3, Cl 106, bicarb 28, creat 1.8, BUN 78, iCa 0.92, Phos 5.3\n Tbili 14, AST 122, ALT 170, AP 133, albumin 2.1, LD 772, CK 182 MB 4\n lactate 4.7\n troponin I 5.6 (today)\n ABG 7.49/36/137 on AC 0.40, 650 x 10, PEEP 5\n HIT Ab : negative (though borderline)\n .\n Micro:\n MRSA nares : negative.\n sputum cx : no growth.\n blood cx : negative\n blood cx , , : NGTD\n BAL : AFB smear neg. culture neg.\n blister : negative.\n urine : negative.\n .\n Images:\n MRI L spine without contrast: limited by motion artifact. Possible R\n lateral disc herniation L4-5 with disc bulging and protrusion.\n .\n TTE : slight LV dilation, normal LV function EF 50-55%. RV\n systolic function mod-severely reduced, RVSP 43. Severe AI.\n Vegetation on aortic valve, prolapses into LVOT. MV mod thickened.\n can't exclude vegetation. ?perforated mitral leaflet. Severe MR.\n Echodensity in the RV appears attached to RV chordae. Mild-mod TR.\n .\n TEE : aortic valve cusps have been essentially destroyed. Large\n vegetation, prolapses into aortic root and into LVOT, severe AI.\n Apparent perforation of anterior mitral leaflet iwth ?vegetation and\n severe MR. TV appears intact. ?small vegetation vs. redudant chordae.\n moderate TR. No abscess seen.\n .\n CT abd/pelvis : large multi locular lesion in spleen 10x0.6x0.8.\n 14 mm round low denisty L adrenal mass. Trace free fluid in pelvis.\n Small to mod bilateral effusions.\n .\n CT abd/pelvis : new decreased enhancement throughout liver -\n ?acute hepatic failure. edema surrounding proximal pancreas.\n Increased free fluid in Abd/pelvis, appears simple. splenic lesion\n unchanged (dictated at 10 x 9.2). increased wall thickening in small\n bowel and colon. appendix not seen. tubular fluid filled structure in\n RLQ measuring 3.3 cm - ?R hydrosalpinx.\n .\n CT head : presence of air fluid levels in paranasal sinuses.\n otherwise no intracranial process.\n .\n CXR : L sided PICC line, ET and OGT, midl central congestion, L\n hemidiaphragm obscured from atelectasis and/or infiltrate plus small\n effusion. Mild atelectasis and/or infiltrate at R base medially.\n .\n CXR (here): L sided PICC, ET and OGT all in good position.\n Cardiomegaly. R sided atelectasis. Bilateral R>L effusions.\n .\n Bronch report : moderate amount of blood in R and L mainstem\n bronchi, seemed to be coming from RLL and LLL. mucosa filled up with\n whitish thick plaques particularly at R mainstem bronchus (concern for\n herpetic infection).\n .\n EKG: sinus tach at 114, NANI, low voltage, poor RWP, nonspecific T wave\n flattening diffusely.\n Assessment and Plan\n 35F with IVDU, congenital single kidney, presenting to OSH s/p fall\n with subsequent development of septic shock, endocarditis, multiple\n sites of bleeding, now transfer to MICU for further management.\n .\n # Septic shock. BPs improving and off pressors now. Source thought to\n be endocarditis, ?other ongoing infection. Likely with multiple sites\n of embolic burden - splenic abscess, ?vertebral osteo per our\n radiologists, ?intraabdominal abscess collection (though per\n descriptions more c/w endometriosis).\n - CVL: Replace and maintain central access; d/c PICC.\n - Replace Aline and dc femoral Aline.\n - Pressors: norepi as first choice if needed.\n - Wean steroids to off.\n - Broad spectrum antibiotics with coverage as detailed below (vanco,\n cefepime, flagyl, acyclovir).\n - Source workup and control: TTE +/- TEE and cardiac surgery consult;\n CT abdomen when stable and general surgery consult; blood, urine,\n sputum, C.diff cultures; ?spine intervention.\n .\n # BRBPR/anemia. In last 24 hours has required 8 units PRBCs in\n addition to cryo, platelets, and FFP. Is POD 4 from ?partial cecectomy\n after concern for bowel ischemia at OSH. OGL negative and low\n suspicion for this being an upper source. No evidence of vaginal\n source on exam.\n - Surgery consult - ?post op bleeding source.\n - GI aware, will see in AM.\n - COnsider IR consult, though above services more likely to be helpful\n in this situation (tics less likely).\n - Attempt to CT abdomen if stability allows.\n - Try to obtain more details regarding operative procedure.\n - Transfuse Hct < 30, sooner if bleeding.\n - Keep plts > 50K, INR < 2, f'gen >100.\n - Monitor calcium.\n - Consider ddAVP if uremia/ARF worsens.\n - IV PPI.\n - Maintain IV access: TLC vs. (more likely if evidence of\n significant ongoing bleeding).\n - Keep NPO.\n .\n # Respiratory failure. Intubated for unclear reasons at OSH, but\n remains intubated for multiple reasons (mental status in particular).\n With significant AI and MR, at risk of acute CHF once positive pressure\n removed.\n - Keep on current vent settings - AC including PEEP 8.\n - Replace Aline.\n - Keep off sedation and monitor respiratory status.\n - Check CT chest if going down for CT abdomen given R sided valvular\n disease to assess for septic emboli.\n .\n # Endocarditis. No organism ever isolated as above. Received\n levofloxacin and zosyn doses prior to blood cultures. 4 sets done at\n OSH all NGTD (on antibiotics). Known high vegetation burden with\n significant valvular compromise. No known abscesses.\n - Monitor for conduction disturbances on tele/ECG.\n - Repeat TTE and likely TEE here.\n - Can go through further detailed records re: ?any other abx before\n blood cultures drawn. Repeat cultures here.\n - Continue IV vanco; high risks of gent/AGs.\n - Cardiac surgery consult in AM.\n - ID consult in AM.\n .\n # Altered mental status. Unclear how much she was given for sedation\n at OSH, but not waking up here. Nonresponsive to painful stimuli of\n extremities, but does seem to react to suctioning. Was on fent gtt at\n OSH and got some fent boluses en route.\n - Hold sedating meds.\n - Repeat head CT with other scans and have our radiologists review OSH\n scan (?poor grey-white matter differentiation).\n .\n # ARF. No known baseline insufficiency. Likely ATN in setting of\n septic shock. Also consider AIN from meds, prerenal or ATN from other\n causes.\n - Renally dose meds.\n - Send urine lytes, eos.\n - CT abdomen will assess for hydro.\n - Renal consult if worsens; currently no indication for acute HD.\n .\n # Coagulopathy. Likely DIC plus some bone marrow suppression from\n severe sepsis, plus synthetic dysfunction in setting of shock liver.\n Heme had been following patient for low plts as well - per OSH heme, no\n schistocytes, and HIT AB negative. Will be difficult to tell\n morphologies on smear after so many blood products.\n - supportive care for now - goal plts > 50, INR > 2, fibrinogen > 100.\n - ?heme onc input here, though OSH did not think TTP to be likely.\n .\n # Hyperbilirubinemia/transaminitis. History of shock liver from\n profound hypotension at OSH. Transaminases improved overall, unclear\n on bilirubin trend. Presumably direct in setting of shock liver, vs.\n indirect if more hemolysis related.\n - Maintain normotensive state.\n - Check direct bili.\n - Avoid hepatic toxins.\n - COntinue to monitor.\n .\n # Leukocytosis. With ongoing infections as above.\n - Empiric C.diff coverage with IV flagyl for now; send C.diff.\n - Other antibiotics as above.\n .\n # ?tracheal HSV. Started on acyclovir following findings of lesions on\n bronch. ?HSV tracheobronchitis +/- pneumonitis. Did not appear to\n send BAL fluid for viral culture. Not known immunocompromised host -\n ?reason for this infection. Definitely with HIV risk factors.\n - Verify negative UPT.\n - Attempt to check HIV status, as would seemingly change management.\n - IV acyclovir at 5 mg/kg Q12H given renal function; though treatment\n with acyclovir in BAL positive ICU patients has not been shown to\n improve outcomes. Low threshold to hold off.\n - Re-bronch tomorrow, send BAL fluid.\n .\n # Necrotic digits. Appearance seems more consistent with necrosis \n pressors, vs. septic emboli. No reason to suspect plain clot as\n emboli, nor acute arterial thrombosis. Great pulses.\n - Maintain off pressors as possible.\n - Management of endocarditis as above.\n - Consider vascular input (more for managment of necrotic digits,\n ?amputation vs. observation). No evidence of current infection.\n .\n # Splenic abscess. Collection stable on imaging at OSH. In this\n clinical context, thought to be abscess more likely than hematoma.\n - CT abd/pelvis now.\n - Surgical consult, if any management appropriate. ?IR input re:\n drainage. COntinue antibiotics.\n .\n # ?Vertebral osteomyelitis. OSH read of MRI benign (though limited),\n some question of osteo by our radiologists on very prelim read.\n - Formal read by our radiologists; consider spine input.\n .\n # NSTEMI. Likely demand in setting of all the above.\n - Trend enzymes.\n - Cannot anticoagulate or give ASA in setting of this bleed. Unclear\n that these would be beneficial with this pathophysiology in addition.\n .\n # Metabolic alkalosis. Has been getting diuresed at OSH; most likely\n contraction alkalosis.\n - Hold lasix in setting of bleed.\n .\n # Hypernatremia. Iatrogenic likely with multiple meds.\n - Replete free water IV as NPO currently.\n .\n # FEN: NPO, IV electrolyte repletion. Glucose control with SSI, low\n threshold to gtt.\n # Prophylaxis: Hold HSQ with low plts, boots, PPI.\n # Access: L PICC needs replacing, R fem line needs replacing.\n # Communication: Patient, family\n # Code: Full\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: NPO, replete lytes\n Glycemic Control: ISS, gtt if needed\n Lines:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 614609, "text": "Chief Complaint:\n Chief Complaint: LUQ pain\n Reason for MICU admission/OSH transfer: septic shock, respiratory\n failure, further management of endocarditis and complications of septic\n shock\n HPI:\n 35F with history of IVDU, initially admitted to OSH on , now\n transferred to MICU for further management of her septic shock,\n endocarditis, and GI bleeding.\n .\n She initially fell on or . With this fall started to\n develop LUQ and mid back pain. She apparently presented to OSH and had\n CTA for rule out PE. This was negative, but she was called back to the\n hospital when CT read to have possible splenic hematoma. She has since\n had a very complicated OSH course with diagnosis of 3 valve\n endocarditis, septic shock, and more recent GI bleeding.\n .\n OSH course:\n overnight - admitted. levofloxacin for ?. dilaudid. neurosurg\n consult for back pain. abd/pelvic CT and surgical consult.\n - MRI lumbar spine.\n - change levoflox to zosyn.\n - crashed and transfer to ICU. intubated. neo, vasopressin,\n and norepi started, 3 units PRBCs, 2 FFP, hydrocortisone. abd/pelvic\n CT. antibiotics - vanco, clinda, zosyn. blood cultures drawn first on\n . TTE with endocarditis. WBCs 40K. L fem line placed. R fem\n Aline placed. Venous pH 6.87.\n - PICC line. 2 FFP, 1 6pk plts. then 4 FFP and 12pk plts preop.\n went to OR for exlap and bowel resection. lactate 14. peak LFTs (14K\n LDH, 9K AST, 3761 ALT).\n - 1 unit PRBCs. hematology consult, vascular consult.\n - bronch, started on IV acyclovir. HIT negative.\n - CT head. 1 6 pack platelets, 2 units PRBCs.\n - overnight transufused 1 or 2 units FFP, vit K, protonix. 4 more\n FFP and total 8 units PRBCs and 12 pack platelets, one unit cryo.\n .\n On the floor, patient arrives intubated and s/p few doses of fentanyl.\n Nonresponsive.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Medications on transfer:\n - Acyclovir 475 mg IV Q12 hours\n - Fluconazole 200 mg IV daily\n - Imipenem 500 mg IV Q12H\n - Vancomycin 1000 mg IV daily\n - Furosemide 80 mg IV BID\n - Hydrocortisone 25 mg IV Q8H\n - Fentanyl gtt\n - Insulin lispro per sliding scale\n - Pantoprazole 40 mg IV daily\n - Combivent 8 puffs Q4H\n .\n Medications at home:\n - Ibuprofen 800 mg Q5 hours prn\n - Diazepam 5 mg 1-2 tabs TID prn spasm\n - Naprosyn 500 mg Q12H prn\n - Percocet 1-2 tabs Q4-6H prn\n Past medical history:\n Family history:\n Social History:\n - Intravenous drug use - heroin, ?others\n - Lumbar disc disease with protrusion\n - Congenital single kidney\n IVDU in multiple family members per OSH notes\n - Tobacco: ~ PPD per patient at presentation.\n - Alcohol: Denied at presentation\n - Illicits: IVDU per family though patient initially denied this.\n Review of systems:\n Review of systems:\n (+) Per HPI\n (-) unable to obtain.\n Flowsheet Data as of 01:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 113 (110 - 114) bpm\n BP: 115/46(76) {111/34(72) - 161/56(152)} mmHg\n RR: 24 (17 - 24) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 626 mL\n PO:\n TF:\n IVF:\n 370 mL\n Blood products:\n 257 mL\n Total out:\n 530 mL\n 80 mL\n Urine:\n 530 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 546 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 95%\n ABG: 7.51/39/345/31/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 690\n Physical Examination\n General: Intubated, nonresponsive to voice, occ cough and ?grimace, but\n otherwise nonresponsive to painful stimuli. Jaundiced.\n HEENT: Very icteric sclera, pupils minimally responsive but equal, ETT\n and OGT in place without obvious OP lesions.\n Neck: supple, JVD difficult to appreciate with large neck, no LAD.\n Lungs: Clear to auscultation bilaterally, no wheezes, rales; occasional\n rhonchi R>L\n CV: Tachy, regular, S1 + S2, SM at apex, ?diastolic murmur at RSUB.\n Abdomen: no apparent bowel sounds. midline incision C/D/I, no\n drainage or bleeding, abdomen generally soft, appears non-tender,\n non-distended, no organomegaly.\n Rectal: bright red blood with some darker clots mixed with minimal\n stool.\n Ext: cool feet and fingers. Marked ischemic/necrotic changes of digits\n of UEs and LEs (L>>R of UEs, R>L of LEs). Palpable pulses of DPs and\n PTs, + LE pitting edema. Scattered large soft blisters over feet\n and lower legs. Scattered dark lesions peripherally ?emboli.\n Neuro: Nonresponsive as above. Not moving extremities. Tone normal.\n Labs / Radiology\n 151\n [image002.gif]\n 109\n [image002.gif]\n 79\n [image004.gif]\n 251\n AGap=14\n [image005.gif]\n 3.0\n [image002.gif]\n 31\n [image002.gif]\n 1.6\n [image007.gif]\n CK: 217\n MB: 3\n Trop-T: 0.34\n Ca: 7.4 Mg: 2.0 P: 5.0\n ALT: 113\n AP: 120\n Tbili: 16.6\n Alb: 2.5\n AST: 116\n LDH: 825\n Dbili: 13.0\n TProt:\n :\n Lip: 128\n TSH:Pnd\n Other Blood Chemistry:\n Vanco: 28.7\n 88\n 20.0\n [image007.gif]\n 12.6\n [image004.gif]\n 69\n [image008.gif]\n [image004.gif]\n 34.8\n [image007.gif]\n N:85 Band:1 L:7 M:3 E:0 Bas:0 Myelos: 3 Promyel: 1 Nrbc: 13\n Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: OCCASIONAL Microcy:\n 1+ Polychr: 1+ Target: OCCASIONAL Schisto: OCCASIONAL Burr: OCCASIONAL\n Plt-Est: Very Low\n PT: 22.4\n PTT: 29.7\n INR: 2.1\n Fibrinogen: 107\n \n 2:33 A1/10/ 09:54 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 32\n Glucose\n 226\n Other labs: Lactic Acid:3.2 mmol/L\n Last known OSH labs:\n WBC 20.6 (last man diff 75N, 13B, 9L, 2M, 1 meta)\n Hct 18.9 (1600 today); 25 (730 today)\n PRBCs at 2200 yest, 200, 400x2, 1000, 1200, 1740x2 (times).\n Plt 101 (1600 today); 13 (730 today)\n INR 2 (1600) - s/p 5 FFP\n vanco 15 (1600 today)\n Na 147, K 3, Cl 106, bicarb 28, creat 1.8, BUN 78, iCa 0.92, Phos 5.3\n Tbili 14, AST 122, ALT 170, AP 133, albumin 2.1, LD 772, CK 182 MB 4\n lactate 4.7\n troponin I 5.6 (today)\n ABG 7.49/36/137 on AC 0.40, 650 x 10, PEEP 5\n HIT Ab : negative (though borderline)\n .\n Micro:\n MRSA nares : negative.\n sputum cx : no growth.\n blood cx : negative\n blood cx , , : NGTD\n BAL : AFB smear neg. culture neg.\n blister : negative.\n urine : negative.\n .\n Images:\n MRI L spine without contrast: limited by motion artifact. Possible R\n lateral disc herniation L4-5 with disc bulging and protrusion.\n .\n TTE : slight LV dilation, normal LV function EF 50-55%. RV\n systolic function mod-severely reduced, RVSP 43. Severe AI.\n Vegetation on aortic valve, prolapses into LVOT. MV mod thickened.\n can't exclude vegetation. ?perforated mitral leaflet. Severe MR.\n Echodensity in the RV appears attached to RV chordae. Mild-mod TR.\n .\n TEE : aortic valve cusps have been essentially destroyed. Large\n vegetation, prolapses into aortic root and into LVOT, severe AI.\n Apparent perforation of anterior mitral leaflet iwth ?vegetation and\n severe MR. TV appears intact. ?small vegetation vs. redudant chordae.\n moderate TR. No abscess seen.\n .\n CT abd/pelvis : large multi locular lesion in spleen 10x0.6x0.8.\n 14 mm round low denisty L adrenal mass. Trace free fluid in pelvis.\n Small to mod bilateral effusions.\n .\n CT abd/pelvis : new decreased enhancement throughout liver -\n ?acute hepatic failure. edema surrounding proximal pancreas.\n Increased free fluid in Abd/pelvis, appears simple. splenic lesion\n unchanged (dictated at 10 x 9.2). increased wall thickening in small\n bowel and colon. appendix not seen. tubular fluid filled structure in\n RLQ measuring 3.3 cm - ?R hydrosalpinx.\n .\n CT head : presence of air fluid levels in paranasal sinuses.\n otherwise no intracranial process.\n .\n CXR : L sided PICC line, ET and OGT, midl central congestion, L\n hemidiaphragm obscured from atelectasis and/or infiltrate plus small\n effusion. Mild atelectasis and/or infiltrate at R base medially.\n .\n CXR (here): L sided PICC, ET and OGT all in good position.\n Cardiomegaly. R sided atelectasis. Bilateral R>L effusions.\n .\n Bronch report : moderate amount of blood in R and L mainstem\n bronchi, seemed to be coming from RLL and LLL. mucosa filled up with\n whitish thick plaques particularly at R mainstem bronchus (concern for\n herpetic infection).\n .\n EKG: sinus tach at 114, NANI, low voltage, poor RWP, nonspecific T wave\n flattening diffusely.\n Assessment and Plan\n 35F with IVDU, congenital single kidney, presenting to OSH s/p fall\n with subsequent development of septic shock, endocarditis, multiple\n sites of bleeding, now transfer to MICU for further management.\n .\n # Septic shock. BPs improving and off pressors now. Source thought to\n be endocarditis, ?other ongoing infection. Likely with multiple sites\n of embolic burden - splenic abscess, ?vertebral osteo per our\n radiologists, ?intraabdominal abscess collection (though per\n descriptions more c/w endometriosis).\n - CVL: Replace and maintain central access; d/c PICC.\n - Replace Aline and dc femoral Aline.\n - Pressors: norepi as first choice if needed.\n - Wean steroids to off.\n - Broad spectrum antibiotics with coverage as detailed below (vanco,\n cefepime, flagyl, acyclovir).\n - Source workup and control: TTE +/- TEE and cardiac surgery consult;\n CT abdomen when stable and general surgery consult; blood, urine,\n sputum, C.diff cultures; ?spine intervention.\n .\n # BRBPR/anemia. In last 24 hours has required 8 units PRBCs in\n addition to cryo, platelets, and FFP. Is POD 4 from ?partial cecectomy\n after concern for bowel ischemia at OSH. OGL negative and low\n suspicion for this being an upper source. No evidence of vaginal\n source on exam.\n - Surgery consult - ?post op bleeding source.\n - GI aware, will see in AM.\n - COnsider IR consult, though above services more likely to be helpful\n in this situation (tics less likely).\n - Attempt to CT abdomen if stability allows.\n - Try to obtain more details regarding operative procedure.\n - Transfuse Hct < 30, sooner if bleeding.\n - Keep plts > 50K, INR < 2, f'gen >100.\n - Monitor calcium.\n - Consider ddAVP if uremia/ARF worsens.\n - IV PPI.\n - Maintain IV access: TLC vs. (more likely if evidence of\n significant ongoing bleeding).\n - Keep NPO.\n .\n # Respiratory failure. Intubated for unclear reasons at OSH, but\n remains intubated for multiple reasons (mental status in particular).\n With significant AI and MR, at risk of acute CHF once positive pressure\n removed.\n - Keep on current vent settings - AC including PEEP 8.\n - Replace Aline.\n - Keep off sedation and monitor respiratory status.\n - Check CT chest if going down for CT abdomen given R sided valvular\n disease to assess for septic emboli.\n .\n # Endocarditis. No organism ever isolated as above. Received\n levofloxacin and zosyn doses prior to blood cultures. 4 sets done at\n OSH all NGTD (on antibiotics). Known high vegetation burden with\n significant valvular compromise. No known abscesses.\n - Monitor for conduction disturbances on tele/ECG.\n - Repeat TTE and likely TEE here.\n - Can go through further detailed records re: ?any other abx before\n blood cultures drawn. Repeat cultures here.\n - Continue IV vanco; high risks of gent/AGs.\n - Cardiac surgery consult in AM.\n - ID consult in AM.\n .\n # Altered mental status. Unclear how much she was given for sedation\n at OSH, but not waking up here. Nonresponsive to painful stimuli of\n extremities, but does seem to react to suctioning. Was on fent gtt at\n OSH and got some fent boluses en route.\n - Hold sedating meds.\n - Repeat head CT with other scans and have our radiologists review OSH\n scan (?poor grey-white matter differentiation).\n .\n # ARF. No known baseline insufficiency. Likely ATN in setting of\n septic shock. Also consider AIN from meds, prerenal or ATN from other\n causes.\n - Renally dose meds.\n - Send urine lytes, eos.\n - CT abdomen will assess for hydro.\n - Renal consult if worsens; currently no indication for acute HD.\n .\n # Coagulopathy. Likely DIC plus some bone marrow suppression from\n severe sepsis, plus synthetic dysfunction in setting of shock liver.\n Heme had been following patient for low plts as well - per OSH heme, no\n schistocytes, and HIT AB negative. Will be difficult to tell\n morphologies on smear after so many blood products.\n - supportive care for now - goal plts > 50, INR > 2, fibrinogen > 100.\n - ?heme onc input here, though OSH did not think TTP to be likely.\n .\n # Hyperbilirubinemia/transaminitis. History of shock liver from\n profound hypotension at OSH. Transaminases improved overall, unclear\n on bilirubin trend. Presumably direct in setting of shock liver, vs.\n indirect if more hemolysis related.\n - Maintain normotensive state.\n - Check direct bili.\n - Avoid hepatic toxins.\n - COntinue to monitor.\n .\n # Leukocytosis. With ongoing infections as above.\n - Empiric C.diff coverage with IV flagyl for now; send C.diff.\n - Other antibiotics as above.\n .\n # ?tracheal HSV. Started on acyclovir following findings of lesions on\n bronch. ?HSV tracheobronchitis +/- pneumonitis. Did not appear to\n send BAL fluid for viral culture. Not known immunocompromised host -\n ?reason for this infection. Definitely with HIV risk factors.\n - Verify negative UPT.\n - Attempt to check HIV status, as would seemingly change management.\n - IV acyclovir at 5 mg/kg Q12H given renal function; though treatment\n with acyclovir in BAL positive ICU patients has not been shown to\n improve outcomes. Low threshold to hold off.\n - Re-bronch tomorrow, send BAL fluid.\n .\n # Necrotic digits. Appearance seems more consistent with necrosis \n pressors, vs. septic emboli. No reason to suspect plain clot as\n emboli, nor acute arterial thrombosis. Great pulses.\n - Maintain off pressors as possible.\n - Management of endocarditis as above.\n - Consider vascular input (more for managment of necrotic digits,\n ?amputation vs. observation). No evidence of current infection.\n .\n # Splenic abscess. Collection stable on imaging at OSH. In this\n clinical context, thought to be abscess more likely than hematoma.\n - CT abd/pelvis now.\n - Surgical consult, if any management appropriate. ?IR input re:\n drainage. COntinue antibiotics.\n .\n # ?Vertebral osteomyelitis. OSH read of MRI benign (though limited),\n some question of osteo by our radiologists on very prelim read.\n - Formal read by our radiologists; consider spine input.\n .\n # NSTEMI. Likely demand in setting of all the above.\n - Trend enzymes.\n - Cannot anticoagulate or give ASA in setting of this bleed. Unclear\n that these would be beneficial with this pathophysiology in addition.\n .\n # Metabolic alkalosis. Has been getting diuresed at OSH; most likely\n contraction alkalosis.\n - Hold lasix in setting of bleed.\n .\n # Hypernatremia. Iatrogenic likely with multiple meds.\n - Replete free water IV as NPO currently.\n .\n # FEN: NPO, IV electrolyte repletion. Glucose control with SSI, low\n threshold to gtt.\n # Prophylaxis: Hold HSQ with low plts, boots, PPI.\n # Access: L PICC needs replacing, R fem line needs replacing.\n # Communication: Patient, family\n # Code: Full\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: NPO, replete lytes\n Glycemic Control: ISS, gtt if needed\n Lines:\n Arterial Line - 10:44 PM\n PICC Line - 10:44 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nutrition", "chartdate": "2191-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 614717, "text": "Subjective\n ht/wt information per note, patient started on tube\n feed ?,tube feed on hold .\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 97.1 kg\n Up 30 kg since outside hospital adm\n 41.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 150% per usual body wt\n 51kg per usual body wt\n 68.18 kg\n 142%\n Diagnosis: ENDOCARDITIS\n PMHx:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Food allergies and intolerances: not available\n Pertinent medications: Hydrocortisone, Insulin SC, Pantoprazole,\n MetRONIDAZOLE , CefePIME, Vancomycin, Calcium Gluconate , Potassium\n Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 264 mg/dL\n 05:40 AM\n Glucose Finger Stick\n 259\n 04:00 AM\n BUN\n 76 mg/dL\n 05:40 AM\n Creatinine\n 1.2 mg/dL\n 05:40 AM\n Sodium\n 151 mEq/L\n 05:40 AM\n Potassium\n 2.6 mEq/L\n 05:46 AM\n Chloride\n 109 mEq/L\n 05:40 AM\n TCO2\n 33 mEq/L\n 05:40 AM\n PO2 (arterial)\n 173 mm Hg\n 08:49 AM\n PCO2 (arterial)\n 37 mm Hg\n 08:49 AM\n pH (arterial)\n 7.54 units\n 08:49 AM\n pH (urine)\n 5.0 units\n 11:16 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 08:49 AM\n Calcium non-ionized\n 7.0 mg/dL\n 05:40 AM\n Phosphorus\n 4.0 mg/dL\n 05:40 AM\n Ionized Calcium\n 0.79 mmol/L\n 08:49 AM\n Magnesium\n 1.9 mg/dL\n 05:40 AM\n ALT\n 81 IU/L\n 05:40 AM\n Alkaline Phosphate\n 99 IU/L\n 05:40 AM\n AST\n 98 IU/L\n 05:40 AM\n Total Bilirubin\n 15.6 mg/dL\n 05:40 AM\n WBC\n 18.2 K/uL\n 05:40 AM\n Hgb\n 11.3 g/dL\n 05:40 AM\n Hematocrit\n 37.5 %\n 08:00 AM\n Current diet order / nutrition support:\n NPO as Diet except Meds;\n Nutrition consult: Tube feeding recommendations\n GI: Abdominal: Soft, Non-tender, No Bowel sounds present, , Obese,\n midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Skin: scattered dark lesions\n Assessment of Nutritional Status\n Obese but at risk for malnutrition\n Patient at risk due to: NPO, critical illness, recent surgery, recent\n BRBPR\n Estimated Nutritional Needs\n Calories: 1275-1428 (BEE x or / 25-28 cal/kg)\n Protein: 61-71 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight per usual body wt\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 35 year old female admitted to outside hospital 10 days ago initially\n with back pain and splenic hematoma. Went into multiorgan failure and\n found to have 3 valve endocarditis - started on broad spectrum abx with\n no organisms recovered. On , due to concern of ischemia with\n lactate of 15, fluid collection on abd CT patient went to the OR for ex\n lap. Cyst found in ovary with adherence to the bowel wall- right\n oophorectomy and partial cecectomy performed. Patient with ARF,\n presumably due to ATN/sepsis, hypernatremia, nutrition consult this\n morning for tube feed recommendation.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Check triglycerides\n Start regular insulin sliding scale if serum glucose greater\n than 150 mg/dL\n Other: \n" }, { "category": "Nutrition", "chartdate": "2191-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 614722, "text": "Subjective\n ht/wt information per note, patient started on tube\n feed ?,tube feed on hold .\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 97.1 kg\n Up 30 kg since outside hospital adm\n 41.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 150% per usual body wt\n 51kg per usual body wt\n 68.18 kg\n 142%\n Diagnosis: ENDOCARDITIS\n PMHx:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Food allergies and intolerances: not available\n Pertinent medications: Hydrocortisone, Insulin SC, Pantoprazole,\n MetRONIDAZOLE , CefePIME, Vancomycin, Calcium Gluconate , Potassium\n Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 264 mg/dL\n 05:40 AM\n Glucose Finger Stick\n 259\n 04:00 AM\n BUN\n 76 mg/dL\n 05:40 AM\n Creatinine\n 1.2 mg/dL\n 05:40 AM\n Sodium\n 151 mEq/L\n 05:40 AM\n Potassium\n 2.6 mEq/L\n 05:46 AM\n Chloride\n 109 mEq/L\n 05:40 AM\n TCO2\n 33 mEq/L\n 05:40 AM\n PO2 (arterial)\n 173 mm Hg\n 08:49 AM\n PCO2 (arterial)\n 37 mm Hg\n 08:49 AM\n pH (arterial)\n 7.54 units\n 08:49 AM\n pH (urine)\n 5.0 units\n 11:16 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 08:49 AM\n Calcium non-ionized\n 7.0 mg/dL\n 05:40 AM\n Phosphorus\n 4.0 mg/dL\n 05:40 AM\n Ionized Calcium\n 0.79 mmol/L\n 08:49 AM\n Magnesium\n 1.9 mg/dL\n 05:40 AM\n ALT\n 81 IU/L\n 05:40 AM\n Alkaline Phosphate\n 99 IU/L\n 05:40 AM\n AST\n 98 IU/L\n 05:40 AM\n Total Bilirubin\n 15.6 mg/dL\n 05:40 AM\n WBC\n 18.2 K/uL\n 05:40 AM\n Hgb\n 11.3 g/dL\n 05:40 AM\n Hematocrit\n 37.5 %\n 08:00 AM\n Current diet order / nutrition support:\n NPO as Diet except Meds;\n Nutrition consult: Tube feeding recommendations\n GI: Abdominal: Soft, Non-tender, No Bowel sounds present, , Obese,\n midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Skin: scattered dark lesions\n Assessment of Nutritional Status\n Obese but at risk for malnutrition\n Patient at risk due to: NPO, critical illness, recent surgery, BRBPR\n Estimated Nutritional Needs\n Calories: 1275-1428 (BEE x or / 25-28 cal/kg)\n Protein: 61-71 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight per usual body wt\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 35 year old female admitted to outside hospital 10 days ago s/p fall\n with back pain. Patient developed RUQ pain, CT on showed ischemic\n bowel and splenic hematoma and echo on showed vegetation on\n AV/TV/MV with AR/MR/TVR and splenic hematoma. On , due to concern of\n ischemia with lactate of 15, patient had ex lap- Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed. , patient started having BRBPR s/p multiple\n blood products, patient transferred to for continue\n management. Nutrition consult this morning for tube feed, consider\n holding tube feed while patient is critically ill, TPN as temporary\n nutrition support if prefer.\n Medical Nutrition Therapy Plan - Recommend the Following\n Hold off nutrition support until medically stable\n TPN if prefer to start: day 1 (150dextrose/70protein), lytes\n pending AM labs, likely will need insulin\n Check chemistry 10 panel daily, replete as you are doing\n Check triglycerides\n Continue regular insulin sliding scale if serum glucose\n greater than 150 mg/dL\n Other: \n This is a 35 yo F with PMH of IVDA (Heroin), congenital single kidney\n disease presents to OSH s/p fall on with pain score of .she\n has been receiving dilaudid for pain.\n On to pt started developing RUQ and was hemodynamically\n decompensated with BP in 60\ns.She was emergently intubated and was on\n triple pressors(Neo/vaso/levophed).. EF 50-55%.\n On pt had Expl Lap with cecal resection and Rt oophrectomy.\n On pt was bronched as she was having BRB through ET.She was\n started on Acyclovir emprirically at that time.\n On pt started having BRBPR with hct drop to 18.9 from\n 27.2.Multiple bld products.On she was transfused PRBC 8units/ cryo\n 1 six pack units/ FFP 3units/ Plts 12.\n She was transferred to for further management of endocarditis, GIB.\n" }, { "category": "Nutrition", "chartdate": "2191-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 614723, "text": "Subjective\n ht/wt information per note, patient started on tube\n feed ?,tube feed on hold .\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 97.1 kg\n Up 30 kg since outside hospital adm\n 41.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 150% per usual body wt\n 51kg per usual body wt\n 68.18 kg\n 142%\n Diagnosis: ENDOCARDITIS\n PMHx:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Food allergies and intolerances: not available\n Pertinent medications: Hydrocortisone, Insulin SC, Pantoprazole,\n MetRONIDAZOLE , CefePIME, Vancomycin, Calcium Gluconate , Potassium\n Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 264 mg/dL\n 05:40 AM\n Glucose Finger Stick\n 259\n 04:00 AM\n BUN\n 76 mg/dL\n 05:40 AM\n Creatinine\n 1.2 mg/dL\n 05:40 AM\n Sodium\n 151 mEq/L\n 05:40 AM\n Potassium\n 2.6 mEq/L\n 05:46 AM\n Chloride\n 109 mEq/L\n 05:40 AM\n TCO2\n 33 mEq/L\n 05:40 AM\n PO2 (arterial)\n 173 mm Hg\n 08:49 AM\n PCO2 (arterial)\n 37 mm Hg\n 08:49 AM\n pH (arterial)\n 7.54 units\n 08:49 AM\n pH (urine)\n 5.0 units\n 11:16 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 08:49 AM\n Calcium non-ionized\n 7.0 mg/dL\n 05:40 AM\n Phosphorus\n 4.0 mg/dL\n 05:40 AM\n Ionized Calcium\n 0.79 mmol/L\n 08:49 AM\n Magnesium\n 1.9 mg/dL\n 05:40 AM\n ALT\n 81 IU/L\n 05:40 AM\n Alkaline Phosphate\n 99 IU/L\n 05:40 AM\n AST\n 98 IU/L\n 05:40 AM\n Total Bilirubin\n 15.6 mg/dL\n 05:40 AM\n WBC\n 18.2 K/uL\n 05:40 AM\n Hgb\n 11.3 g/dL\n 05:40 AM\n Hematocrit\n 37.5 %\n 08:00 AM\n Current diet order / nutrition support:\n NPO as Diet except Meds;\n Nutrition consult: Tube feeding recommendations\n GI: Abdominal: Soft, Non-tender, No Bowel sounds present, , Obese,\n midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Skin: scattered dark lesions\n Assessment of Nutritional Status\n Obese but at risk for malnutrition\n Patient at risk due to: NPO, critical illness, recent surgery, BRBPR,\n sever volume overload, potential surgeries\n Estimated Nutritional Needs\n Calories: 1275-1428 (BEE x or / 25-28 cal/kg)\n Protein: 61-71 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight per usual body wt\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 35 year old female admitted to outside hospital 10 days ago s/p fall\n with back pain. Patient developed RUQ pain, CT on showed ischemic\n bowel and splenic hematoma and echo on showed vegetation on\n AV/TV/MV with AR/MR/TVR and splenic hematoma. On , due to concern of\n ischemia with lactate of 15, patient had ex lap- Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed. , patient started having BRBPR s/p multiple\n blood products, patient transferred to for continue\n management. Nutrition consult this morning for tube feed, consider\n holding tube feed while patient is critically ill, TPN as temporary\n nutrition support if prefer.\n Medical Nutrition Therapy Plan - Recommend the Following\n Hold off nutrition support until medically stable\n TPN if prefer to start: day 1 (150dextrose/70protein), lytes\n pending AM labs, likely will need insulin\n Check chemistry 10 panel daily, replete as you are doing\n Check triglycerides\n Continue regular insulin sliding scale if serum glucose\n greater than 150 mg/dL\n Other: \n" }, { "category": "Nutrition", "chartdate": "2191-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 614725, "text": "Subjective\n ht/wt information per note, RD consulted for tube\n feed, ? patient tolerated tube feed as no other info available.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 97.1 kg\n Up 30 kg since outside hospital adm\n 41.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 150% per usual body wt\n 51kg per usual body wt\n 68.18 kg\n 142%\n Diagnosis: ENDOCARDITIS\n PMHx:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Food allergies and intolerances: not available\n Pertinent medications: Hydrocortisone, Insulin SC, Pantoprazole,\n MetRONIDAZOLE , CefePIME, Vancomycin, Calcium Gluconate , Potassium\n Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 264 mg/dL\n 05:40 AM\n Glucose Finger Stick\n 259\n 04:00 AM\n BUN\n 76 mg/dL\n 05:40 AM\n Creatinine\n 1.2 mg/dL\n 05:40 AM\n Sodium\n 151 mEq/L\n 05:40 AM\n Potassium\n 2.6 mEq/L\n 05:46 AM\n Chloride\n 109 mEq/L\n 05:40 AM\n TCO2\n 33 mEq/L\n 05:40 AM\n PO2 (arterial)\n 173 mm Hg\n 08:49 AM\n PCO2 (arterial)\n 37 mm Hg\n 08:49 AM\n pH (arterial)\n 7.54 units\n 08:49 AM\n pH (urine)\n 5.0 units\n 11:16 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 08:49 AM\n Calcium non-ionized\n 7.0 mg/dL\n 05:40 AM\n Phosphorus\n 4.0 mg/dL\n 05:40 AM\n Ionized Calcium\n 0.79 mmol/L\n 08:49 AM\n Magnesium\n 1.9 mg/dL\n 05:40 AM\n ALT\n 81 IU/L\n 05:40 AM\n Alkaline Phosphate\n 99 IU/L\n 05:40 AM\n AST\n 98 IU/L\n 05:40 AM\n Total Bilirubin\n 15.6 mg/dL\n 05:40 AM\n WBC\n 18.2 K/uL\n 05:40 AM\n Hgb\n 11.3 g/dL\n 05:40 AM\n Hematocrit\n 37.5 %\n 08:00 AM\n Current diet order / nutrition support:\n NPO as Diet except Meds;\n Nutrition consult: Tube feeding recommendations\n GI: Abdominal: Soft, Non-tender, No Bowel sounds present, Obese,\n midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Skin: scattered dark lesions\n Assessment of Nutritional Status\n Obese but at risk for malnutrition\n Patient at risk due to: NPO, critical illness, recent surgery, BRBPR,\n sever volume overload, potential surgeries\n Estimated Nutritional Needs\n Calories: 1275-1428 (BEE x or / 25-28 cal/kg)\n Protein: 61-71 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight per usual body wt\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 35 year old female admitted to outside hospital 10 days ago s/p fall\n with back pain. Patient developed RUQ pain, CT on showed ischemic\n bowel and splenic hematoma and echo on showed vegetation on\n AV/TV/MV with AR/MR/TVR and splenic hematoma. On , due to concern of\n ischemia with lactate of 15, patient had ex lap- Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed. , patient started having BRBPR s/p multiple\n blood products, patient transferred to for continue\n management. Nutrition consult this morning for tube feed, consider\n holding tube feed while patient is critically ill, TPN as temporary\n nutrition support if prefer.\n Medical Nutrition Therapy Plan - Recommend the Following\n Hold off nutrition support until medically stable\n TPN if prefer to start: day 1 (150dextrose/70protein), lytes\n pending AM labs, likely will need insulin\n Check chemistry 10 panel daily, replete as you are doing\n Check triglycerides\n Continue regular insulin sliding scale if serum glucose\n greater than 150 mg/dL\n Other: \n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 614726, "text": "Chief Complaint: IVDU -> endocarditis (left) -> septic emboli to spleen\n -> sepsis & more trashing -> MOD (including shock liver and likely\n mesenteric infarction & myocardial demand ischemia with troponin leak.\n Given suspected SMA thrombus on CT, laparotomy was performed.\n Ileocecal stricture noted and resected with anastomosis. Began large\n BRBPR on . IR intervention considered, but in view of numerous\n problems and instability was transferred here.\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n PAN CULTURE - At 10:09 PM\n ARTERIAL LINE - START 10:44 PM\n PICC LINE - START 10:44 PM\n ARTERIAL LINE - START 06:30 AM\n - Placed A-line and -IJ\n - Continued to bleed - most recent BM frank blood\n - Hemodynamically relatively stable\n - Family here - discussed critical condition\n - Has been non-responsive\n - Only very rare purposeless movement\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Cefipime - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 108 (103 - 115) bpm\n BP: 117/44(69) {110/34(69) - 161/56(152)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,083 mL\n PO:\n TF:\n IVF:\n 486 mL\n Blood products:\n 1,847 mL\n Total out:\n 530 mL\n 805 mL\n Urine:\n 530 mL\n 805 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 2,278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 100%\n ABG: 7.56/37/194/33/10\n Ve: 8.9 L/min\n PaO2 / FiO2: 485\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 40 K/uL\n 11.3 g/dL\n 264 mg/dL\n 1.2 mg/dL\n 33 mEq/L\n 2.6 mEq/L\n 76 mg/dL\n 109 mEq/L\n 151 mEq/L\n 30.8 %\n 18.2 K/uL\n [image002.jpg]\n 09:54 PM\n 01:15 AM\n 05:40 AM\n 05:46 AM\n WBC\n 18.2\n Hct\n 29.9\n 30.8\n Plt\n 40\n Cr\n 1.2\n TCO2\n 32\n 34\n Glucose\n 226\n 264\n Other labs: PT / PTT / INR:23.2/33.9/2.2, ALT / AST:81/98, Alk Phos / T\n Bili:99/15.6, Differential-Neuts:84.0 %, Lymph:11.8 %, Mono:3.3 %,\n Eos:0.2 %, Lactic Acid:2.7 mmol/L, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis\n 1. Septic shock: hemodynamics improving, off pressors\n Continue antibiotics with vanco (dose by levels); cefipime for possible\n VAP\n Repeat echo\n Recheck Echo's, cultures\n ID consult\n Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n 2. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, none since\n Correct coagulopathy if recurrent bleeding (INR<1.5, plts>50)\n GI and Surgery involved\n 3. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings\n Wean FiO2 as tolerated, keep on AC.\n 4. Altered mental status- could be partly from sedative, need to also\n be concerned about embolic CVA- will obtain head CT, limit sedating\n meds\n 5. Coagulopathy/DIC + sepsis.\n 6. ARF- Cr 1.6 presumably due to ATN/sepsis. Will check U/A, urine\n 'lytes, avoid nephrotoxins\n 7. Hypernatremia: will correct with free water\n 8. NSTEMI: secondary to demand\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:44 PM\n Arterial Line - 06:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2191-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 614729, "text": "Subjective\n ht/wt information per note, RD consulted for tube\n feed, ? patient tolerated tube feed as no other info available.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 97.1 kg\n Up 30 kg since outside hospital adm\n 41.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 150% per usual body wt\n 51kg per usual body wt\n 68.18 kg\n 142%\n Diagnosis: ENDOCARDITIS\n PMHx:\n IVDA\n Lumbar disc protrusion\n Congenital single kidney\n Food allergies and intolerances: not available\n Pertinent medications: Hydrocortisone, Insulin SC, Pantoprazole,\n MetRONIDAZOLE , CefePIME, Vancomycin, Calcium Gluconate , Potassium\n Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 264 mg/dL\n 05:40 AM\n Glucose Finger Stick\n 259\n 04:00 AM\n BUN\n 76 mg/dL\n 05:40 AM\n Creatinine\n 1.2 mg/dL\n 05:40 AM\n Sodium\n 151 mEq/L\n 05:40 AM\n Potassium\n 2.6 mEq/L\n 05:46 AM\n Chloride\n 109 mEq/L\n 05:40 AM\n TCO2\n 33 mEq/L\n 05:40 AM\n PO2 (arterial)\n 173 mm Hg\n 08:49 AM\n PCO2 (arterial)\n 37 mm Hg\n 08:49 AM\n pH (arterial)\n 7.54 units\n 08:49 AM\n pH (urine)\n 5.0 units\n 11:16 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 08:49 AM\n Calcium non-ionized\n 7.0 mg/dL\n 05:40 AM\n Phosphorus\n 4.0 mg/dL\n 05:40 AM\n Ionized Calcium\n 0.79 mmol/L\n 08:49 AM\n Magnesium\n 1.9 mg/dL\n 05:40 AM\n ALT\n 81 IU/L\n 05:40 AM\n Alkaline Phosphate\n 99 IU/L\n 05:40 AM\n AST\n 98 IU/L\n 05:40 AM\n Total Bilirubin\n 15.6 mg/dL\n 05:40 AM\n WBC\n 18.2 K/uL\n 05:40 AM\n Hgb\n 11.3 g/dL\n 05:40 AM\n Hematocrit\n 37.5 %\n 08:00 AM\n Current diet order / nutrition support:\n NPO as Diet except Meds;\n Nutrition consult: Tube feeding recommendations\n GI: Abdominal: Soft, Non-tender, No Bowel sounds present, Obese,\n midline surgical incisions clear\n Extremities: cool distal UE/LE's, black digits, probable embolic\n phenomenon on both feet\n Skin: scattered dark lesions\n Assessment of Nutritional Status\n Obese but at risk for malnutrition\n Patient at risk due to: NPO, critical illness, recent surgery, BRBPR,\n sever volume overload, potential surgeries\n Estimated Nutritional Needs\n Calories: 1275-1428 (BEE x or / 25-28 cal/kg)\n Protein: 61-71 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight per usual body wt\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 35 year old female admitted to outside hospital 10 days ago s/p fall\n with back pain. Patient developed RUQ pain, CT on showed ischemic\n bowel and splenic hematoma and echo on showed vegetation on\n AV/TV/MV with AR/MR/TVR and splenic hematoma. On , due to concern of\n ischemia with lactate of 15, patient had ex lap- Cyst found in ovary\n with adherence to the bowel wall- right oophorectomy and partial\n cecectomy performed. , patient started having BRBPR s/p multiple\n blood products, patient transferred to for continue\n management. Nutrition consult this morning for tube feed, consider\n holding tube feed while patient is critically ill, TPN as temporary\n nutrition support if prefer.\n Medical Nutrition Therapy Plan - Recommend the Following\n Hold off nutrition support until medically stable\n TPN if prefer to start: day 1 (150dextrose/70protein), lytes\n pending AM labs, likely will need insulin\n Check chemistry 10 panel daily, replete as you are doing\n Check triglycerides\n Continue regular insulin sliding scale if serum glucose\n greater than 150 mg/dL\n Other: \n ------ Protected Section ------\n Height should be 152cm, above height recorded by mistake.\n ------ Protected Section Addendum Entered By: , RD, \n on: 11:42 AM ------\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 614731, "text": "Chief Complaint: IVDU -> endocarditis (left) -> septic emboli to spleen\n -> sepsis & more trashing -> MOD (including shock liver and likely\n mesenteric infarction & myocardial demand ischemia with troponin leak.\n Given suspected SMA thrombus on CT, laparotomy was performed.\n Ileocecal stricture noted and resected with anastomosis. Began large\n BRBPR on . IR intervention considered, but in view of numerous\n problems and instability was transferred here.\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n PAN CULTURE - At 10:09 PM\n ARTERIAL LINE - START 10:44 PM\n PICC LINE - START 10:44 PM\n ARTERIAL LINE - START 06:30 AM\n - Placed A-line and -IJ\n - Continued to bleed - most recent BM frank blood\n - Hemodynamically relatively stable\n - Family here - discussed critical condition\n - Has been non-responsive\n - Only very rare purposeless movement\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Cefipime - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 108 (103 - 115) bpm\n BP: 117/44(69) {110/34(69) - 161/56(152)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,083 mL\n PO:\n TF:\n IVF:\n 486 mL\n Blood products:\n 1,847 mL\n Total out:\n 530 mL\n 805 mL\n Urine:\n 530 mL\n 805 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 2,278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 100%\n ABG: 7.56/37/194/33/10\n Ve: 8.9 L/min\n PaO2 / FiO2: 485\n Physical Examination\n General: Intubated, nonresponsive to voice, rare spontaneous movements\n without purpose. Jaundiced.\n HEENT: Very icteric sclera, pupils minimally responsive but equal, ETT\n and OGT in place without obvious OP lesions. Fair dentition.\n Neck: supple, JVD difficult to appreciate with large neck, no LAD.\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales;\n occasional rhonchi R>L\n CV: Tachy, regular, S1 + S2, SM at apex, ?diastolic murmur at RSUB.\n Abdomen: no apparent bowel sounds. midline incision C/D/I, no\n drainage or bleeding, abdomen generally soft, appears non-tender,\n non-distended, no organomegaly.\n Rectal: bright red blood with some darker clots mixed with minimal\n stool.\n Ext: cool feet and fingers. Marked ischemic/necrotic changes of digits\n of UEs and LEs (L>>R of UEs, R>L of LEs). Palpable pulses of DPs and\n PTs, + LE pitting edema. Scattered large soft blisters over feet\n and lower legs. Scattered dark lesions peripherally ?emboli.\n Labs / Radiology\n 40 K/uL\n 11.3 g/dL\n 264 mg/dL\n 1.2 mg/dL\n 33 mEq/L\n 2.6 mEq/L\n 76 mg/dL\n 109 mEq/L\n 151 mEq/L\n 30.8 %\n 18.2 K/uL\n [image002.jpg]\n 09:54 PM\n 01:15 AM\n 05:40 AM\n 05:46 AM\n WBC\n 18.2\n Hct\n 29.9\n 30.8\n Plt\n 40\n Cr\n 1.2\n TCO2\n 32\n 34\n Glucose\n 226\n 264\n Other labs: PT / PTT / INR:23.2/33.9/2.2, ALT / AST:81/98, Alk Phos / T\n Bili:99/15.6, Differential-Neuts:84.0 %, Lymph:11.8 %, Mono:3.3 %,\n Eos:0.2 %, Lactic Acid:2.7 mmol/L, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis. Briefly, IVDU -> endocarditis (left) ->\n septic emboli to spleen -> sepsis & more trashing -> MOD (including\n shock liver and likely mesenteric infarction & myocardial demand\n ischemia with troponin leak. Given suspected SMA thrombus on CT,\n laparotomy was performed. Ileocecal stricture noted and resected with\n anastomosis. Began large BRBPR on . IR intervention considered, but\n in view of numerous problems and instability was transferred here.\n Emergent issues at present are BRBPR and control or source. Therefore\n discussion with IR and Surgery. Beyond that valvular disease is most\n important, but patient will need to be free of collections/risk of\n sepsis prior to management. Neurologic status concerning. Overall\n prognosis very poor at present.\n #. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, briefly\n stabilized then worsened substantially this a.m. most likely source is\n new anastomosis given presentation.\n - Continue delivering products with ratio 1:1 for FFP and PRBCs then\n 1:4 for platelet and PRBCs given coagulopathy.\n - Goals of INR < 1.8 if possible, HCt of 30, keep platelets above 50\n - GI and Surgery involved, along with IR\n will discuss possible\n operative management\n #. Septic shock\n Acutally hemodynamically stable at present, although pressure is\n gradually falling.\n - Broad cover to include translocation: Vancomycin, flagyl, cefepime.\n - Follow cultures\n - Discuss with ID\n - Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n #. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings. ARDS-like picture, therefore:\n - Adjust VT to lower volumes per ARDS ventilation\n - Wean FiO2 as tolerated, keep on AC.\n - Sedation if necessary (unlikely in view of mental status)\n #. Altered mental status\n Concern for septic emboli to brain, possible abcess, although not seen\n on CT on . CT not a great study at OSH, but concerning for hypoxic\n brain injury.\n - Repeat head CT\n - Avoid sedative meds unless absolutely necessary.\n #. Coagulopathy/DIC + sepsis.\n - Follow coags (shock liver versus consumption or both)\n - Fibrinogen level\n - Blood products as above.\n #. ARF- Cr 1.6 presumably due to ATN/sepsis/hypotension.\n - Improving\n - Microscopy and lytes.\n #. Electrolyte disturbance\n - Aggressively replete K, Ca, others.\n #. NSTEMI: secondary to demand\n - No intervention at this time\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:44 PM\n Arterial Line - 06:30 AM\n Prophylaxis:\n DVT: None\n is coagulopathic\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2191-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 614600, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 614668, "text": "Chief Complaint: IVDU -> endocarditis (left) -> septic emboli to spleen\n -> sepsis & more trashing -> MOD (including shock liver and likely\n mesenteric infarction & myocardial demand ischemia with troponin leak.\n Therefore transferred here.\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n PAN CULTURE - At 10:09 PM\n ARTERIAL LINE - START 10:44 PM\n PICC LINE - START 10:44 PM\n ARTERIAL LINE - START 06:30 AM\n - Placed A-line and -IJ\n - Continued to bleed - most recent BM frank blood\n - Hemodynamically relatively stable\n - Family here - discussed critical condition\n - Has been non-responsive\n - Only very rare purposeless movement\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Cefipime - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 108 (103 - 115) bpm\n BP: 117/44(69) {110/34(69) - 161/56(152)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,083 mL\n PO:\n TF:\n IVF:\n 486 mL\n Blood products:\n 1,847 mL\n Total out:\n 530 mL\n 805 mL\n Urine:\n 530 mL\n 805 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 2,278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 100%\n ABG: 7.56/37/194/33/10\n Ve: 8.9 L/min\n PaO2 / FiO2: 485\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 40 K/uL\n 11.3 g/dL\n 264 mg/dL\n 1.2 mg/dL\n 33 mEq/L\n 2.6 mEq/L\n 76 mg/dL\n 109 mEq/L\n 151 mEq/L\n 30.8 %\n 18.2 K/uL\n [image002.jpg]\n 09:54 PM\n 01:15 AM\n 05:40 AM\n 05:46 AM\n WBC\n 18.2\n Hct\n 29.9\n 30.8\n Plt\n 40\n Cr\n 1.2\n TCO2\n 32\n 34\n Glucose\n 226\n 264\n Other labs: PT / PTT / INR:23.2/33.9/2.2, ALT / AST:81/98, Alk Phos / T\n Bili:99/15.6, Differential-Neuts:84.0 %, Lymph:11.8 %, Mono:3.3 %,\n Eos:0.2 %, Lactic Acid:2.7 mmol/L, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis\n 1. Septic shock: hemodynamics improving, off pressors\n Continue antibiotics with vanco (dose by levels); cefipime for possible\n VAP\n Repeat echo\n Recheck Echo's, cultures\n ID consult\n Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n 2. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, none since\n Correct coagulopathy if recurrent bleeding (INR<1.5, plts>50)\n GI and Surgery involved\n 3. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings\n Wean FiO2 as tolerated, keep on AC.\n 4. Altered mental status- could be partly from sedative, need to also\n be concerned about embolic CVA- will obtain head CT, limit sedating\n meds\n 5. Coagulopathy/DIC + sepsis.\n 6. ARF- Cr 1.6 presumably due to ATN/sepsis. Will check U/A, urine\n 'lytes, avoid nephrotoxins\n 7. Hypernatremia: will correct with free water\n 8. NSTEMI: secondary to demand\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:44 PM\n Arterial Line - 06:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Social Work", "chartdate": "2191-01-31 00:00:00.000", "description": "Social Work Admission Note", "row_id": 614788, "text": "Social Work Initial Note:\n Received page for family support while pt was coding in MICU this\n afternoon. Pt is a 35 y.o. woman transferred to from OSH on\n with dx of endocarditis. Per medical record, PMH includes h/o\n heroin abuse.\n SW stayed with family\n mother, father, step-mother, step-father, and\n brother\n while they chose to watch code; offered emotional support for\n family throughout process. After code, father states he feels better\nknowing everything was done to save\n pt and that he appreciated\n opportunity to watch code, however difficult.\n SW met with mother, step-father, and brother afterwards and offered\n additional emotional and resource support. Discussed funeral planning\n and supported mother as she begins to make phone calls to other\n relatives and plan next steps. Provided assistance with parking.\n Catholic priest present for anointing.\n A/P: Pt\ns family members appear to be coping within normal limits at\n this time using one another well for support. No further SW\n intervention planned, though encouraged mother to call as needed should\n other questions or concerns arise in the coming days. Discussed with\n RN.\n , LICSW, #\n" }, { "category": "Nursing", "chartdate": "2191-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614792, "text": "Pt with septic shock endocarditis, also with large amounts of\n BRBPR, given total of 8 units pRBC, 8 units FFP, 2 units platelets, 1\n unit cryo, 1 dose factor 7 for anemia and coagulopathy in setting of\n active bleed. ECHO done to assess known vegetations, electrolytes\n repleted, FiO2 and Peep increased as sats and PO2 decreased. All\n antibiotics per ID recs given. Prior to pt traveling to IR to find\n source of bleed, her family came in to see her. Approximately 5\n minutes after family left ICU pt found to have HR 70s, from 150s, with\n wide complexes. Pt then became pulseless. CPR initiated by ICU team\n (see code sheet for specifics). Family brought into pt\ns room. Father\n anointed pt during code. Code called at 1525, 30 minutes after\n initiation. and this RN met with family after the\n code, family both devastated and appreciative. The verbalized\n understanding all the circumstances. Pt then sent to morgue for\n autopsy, she had no personal belongings.\n" }, { "category": "Nursing", "chartdate": "2191-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614590, "text": "This is a 35 yo F with PMH of IVDA (Heroin), congenital single kidney\n disease presents to OSH s/p fall on with pain score of .she\n has been receiving dilaudid for pain.\n On to pt started developing RUQ and was hemodynamically\n decompensated with BP in 60\ns.She was emergently intubated and was on\n triple pressors(Neo/vaso/levophed). CT on showed ischemic bowel\n and splenic hematoma and echo on showed vegetation on AV/TV/MV\n with AR/MR/TVR. EF 50-55%.\n On pt had Expl Lap with cecal resection and Rt oophrectomy.\n On pt was bronched as she was having BRB through ET.She was\n started on Acyclovir emprirically at that time.\n On pt started having BRBPR with hct drop to 18.9 from\n 27.2.Multiple bld products.On she was transfused PRBC 8units/ cryo\n 1 six pack units/ FFP 3units/ Plts 12.\n She was transferred to for further management of endocarditis, GIB.\n" }, { "category": "Nursing", "chartdate": "2191-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 614664, "text": "This is a 35 yo F with PMH of IVDA (Heroin), congenital single kidney\n disease presents to OSH s/p fall on with pain score of .she\n has been receiving dilaudid for pain.\n On to pt started developing RUQ and was hemodynamically\n decompensated with BP in 60\ns.She was emergently intubated and was on\n triple pressors(Neo/vaso/levophed). CT on showed ischemic bowel\n and splenic hematoma and echo on showed vegetation on AV/TV/MV\n with AR/MR/TVR. EF 50-55%.\n On pt had Expl Lap with cecal resection and Rt oophrectomy.\n On pt was bronched as she was having BRB through ET.She was\n started on Acyclovir emprirically at that time.\n On pt started having BRBPR with hct drop to 18.9 from\n 27.2.Multiple bld products.On she was transfused PRBC 8units/ cryo\n 1 six pack units/ FFP 3units/ Plts 12.\n She was transferred to for further management of endocarditis, GIB.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt with shock liver.ALT and AST in 9000 at the OSH.Here in 100\ns.In\n acute renal failure with Cr 1.8 at OSH.CR 1.6 last night.Pt with black\n cool finger tips with blisters.Pos pulses.WCC 20.Lactate 5 at the OSH.\n Action:\n Started on cefepime.Pt on IV Vanc/Acyclovir from OSH.\n Response:\n Ongoing.Lactate trending down.2.7 this am.Consult Vascular.\n Plan:\n Cont IV Abx.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt with BRPRB x4 since admission.Had x6 at the OSH.Hct on arrival was\n 34 s/p 8 units of PRBC transfusion.Hct trending down since\n.INR\n 2.0\n Action:\n Pt had 2 units FFP and is getting the 4^th unit PRBC.GI and general\n seen pt.\n Response:\n Hct 30.0 s/p 2units PRBC.Not a candidate for surgery, not for\n colonoscopy.\n Plan:\n Monitor hct, correct coags.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd pt vented.Not sedated.Pt is unresponsive to painful stimuli.PEARL\n size 3.\n Action:\n Put on AC/100%/500/16/8.\n Response:\n Bld gases with metabolic alkalosis.Decreased TV to 450 and O2 down to\n 60%-->40%.\n Plan:\n Monitor bld gases, wean vent as tolerated.\n Endocarditis, Other\n Assessment:\n Pt with triple valve endocarditis from OSH.\n Action:\n On IV Abx\n Response:\n ongoing\n Plan:\n Cardio consult.\n Receiving K for K of 2.6.\n" }, { "category": "General", "chartdate": "2191-01-31 00:00:00.000", "description": "Generic Note", "row_id": 614781, "text": "TITLE:\n MICU Resident Event/Death note:\n At 2:58pm patient became acutely bradycardic to the 30s. Initially she\n had her pulse, however within a few minutes she lost her pulse and\n chest compressions along with ACLS protocol was initiated. She\n received multiple rounds of epi, atropine, bicarb along with Ca, and\n magnesium.\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 614783, "text": "Chief Complaint: IVDU -> endocarditis (left) -> septic emboli to spleen\n -> sepsis & more trashing -> MOD (including shock liver and likely\n mesenteric infarction & myocardial demand ischemia with troponin leak.\n Given suspected SMA thrombus on CT, laparotomy was performed.\n Ileocecal stricture noted and resected with anastomosis. Began large\n BRBPR on . IR intervention considered, but in view of numerous\n problems and instability was transferred here.\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n PAN CULTURE - At 10:09 PM\n ARTERIAL LINE - START 10:44 PM\n PICC LINE - START 10:44 PM\n ARTERIAL LINE - START 06:30 AM\n - Placed A-line and -IJ\n - Continued to bleed - most recent BM frank blood\n - Hemodynamically relatively stable\n - Family here - discussed critical condition\n - Has been non-responsive\n - Only very rare purposeless movement\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Cefipime - 12:00 AM\n Acyclovir - 12:45 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:01 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 108 (103 - 115) bpm\n BP: 117/44(69) {110/34(69) - 161/56(152)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,083 mL\n PO:\n TF:\n IVF:\n 486 mL\n Blood products:\n 1,847 mL\n Total out:\n 530 mL\n 805 mL\n Urine:\n 530 mL\n 805 mL\n NG:\n Stool:\n Drains:\n Balance:\n -530 mL\n 2,278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 100%\n ABG: 7.56/37/194/33/10\n Ve: 8.9 L/min\n PaO2 / FiO2: 485\n Physical Examination\n General: Intubated, nonresponsive to voice, rare spontaneous movements\n without purpose. Jaundiced.\n HEENT: Very icteric sclera, pupils minimally responsive but equal, ETT\n and OGT in place without obvious OP lesions. Fair dentition.\n Neck: supple, JVD difficult to appreciate with large neck, no LAD.\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales;\n occasional rhonchi R>L\n CV: Tachy, regular, S1 + S2, SM at apex, ?diastolic murmur at RSUB.\n Abdomen: no apparent bowel sounds. midline incision C/D/I, no\n drainage or bleeding, abdomen generally soft, appears non-tender,\n non-distended, no organomegaly.\n Rectal: bright red blood with some darker clots mixed with minimal\n stool.\n Ext: cool feet and fingers. Marked ischemic/necrotic changes of digits\n of UEs and LEs (L>>R of UEs, R>L of LEs). Palpable pulses of DPs and\n PTs, + LE pitting edema. Scattered large soft blisters over feet\n and lower legs. Scattered dark lesions peripherally ?emboli.\n Labs / Radiology\n 40 K/uL\n 11.3 g/dL\n 264 mg/dL\n 1.2 mg/dL\n 33 mEq/L\n 2.6 mEq/L\n 76 mg/dL\n 109 mEq/L\n 151 mEq/L\n 30.8 %\n 18.2 K/uL\n [image002.jpg]\n 09:54 PM\n 01:15 AM\n 05:40 AM\n 05:46 AM\n WBC\n 18.2\n Hct\n 29.9\n 30.8\n Plt\n 40\n Cr\n 1.2\n TCO2\n 32\n 34\n Glucose\n 226\n 264\n Other labs: PT / PTT / INR:23.2/33.9/2.2, ALT / AST:81/98, Alk Phos / T\n Bili:99/15.6, Differential-Neuts:84.0 %, Lymph:11.8 %, Mono:3.3 %,\n Eos:0.2 %, Lactic Acid:2.7 mmol/L, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n 35 yo female with IVD admitted with septic shock/multi organ failure\n and 3 valve endocarditis. Briefly, IVDU -> endocarditis (left) ->\n septic emboli to spleen -> sepsis & more trashing -> MOD (including\n shock liver and likely mesenteric infarction & myocardial demand\n ischemia with troponin leak. Given suspected SMA thrombus on CT,\n laparotomy was performed. Ileocecal stricture noted and resected with\n anastomosis. Began large BRBPR on . IR intervention considered, but\n in view of numerous problems and instability was transferred here.\n Emergent issues at present are BRBPR and control or source. Therefore\n discussion with IR and Surgery. Beyond that valvular disease is most\n important, but patient will need to be free of collections/risk of\n sepsis prior to management. Neurologic status concerning. Overall\n prognosis very poor at present.\n #. BRBPR/acute blood loss anemia\n Pt had one episode of rectal bleeding upon ICU arrival, briefly\n stabilized then worsened substantially this a.m. most likely source is\n new anastomosis given presentation.\n - Continue delivering products with ratio 1:1 for FFP and PRBCs then\n 1:4 for platelet and PRBCs given coagulopathy.\n - Goals of INR < 1.8 if possible, HCt of 30, keep platelets above 50\n - GI and Surgery involved, along with IR\n will discuss possible\n operative management\n #. Septic shock\n Acutally hemodynamically stable at present, although pressure is\n gradually falling.\n - Broad cover to include translocation: Vancomycin, flagyl, cefepime.\n - Follow cultures\n - Discuss with ID\n - Various fluid collections presumably embolic-scan chest/abdomen for\n further eval\n #. Acute respiratory failure: oxygenation and ventilation adequate on\n current settings. ARDS-like picture, therefore:\n - Adjust VT to lower volumes per ARDS ventilation\n - Wean FiO2 as tolerated, keep on AC.\n - Sedation if necessary (unlikely in view of mental status)\n #. Altered mental status\n Concern for septic emboli to brain, possible abcess, although not seen\n on CT on . CT not a great study at OSH, but concerning for hypoxic\n brain injury.\n - Repeat head CT\n - Avoid sedative meds unless absolutely necessary.\n #. Coagulopathy/DIC + sepsis.\n - Follow coags (shock liver versus consumption or both)\n - Fibrinogen level\n - Blood products as above.\n #. ARF- Cr 1.6 presumably due to ATN/sepsis/hypotension.\n - Improving\n - Microscopy and lytes.\n #. Electrolyte disturbance\n - Aggressively replete K, Ca, others.\n #. NSTEMI: secondary to demand\n - No intervention at this time\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:44 PM\n Arterial Line - 06:30 AM\n Prophylaxis:\n DVT: None\n is coagulopathic\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 35F hx IVDU, endocarditis (unknown\n organism) c/b respiratory failure, DIC, massive GIB, shock liver,\n profound acidosis and refractory shock. OSH eval notable for splenic\n hematoma / abscess, back pain concerning for osteo / paraspinal\n collection, echo c AI, MR, TR and vegitations likely on all valves. HC\n notable for trip to OR, R oophrectomy, ileocecal resection /\n reanastomosis (details unclear in available chart). Currently off\n pressors but with very brisk GIB, likely lower - transfused 16 PRBC, 14\n FFP, 4 PLTS over 36 hours with escalating requirement. Since admission,\n she has been seen by GI and surgery, / art line placed.\n Exam notable for Tm 100.4 BP 134/70 HR 115 RR 18 with sat 96 on VAC\n 450x14 8 1.0. Mottled, minimally responsive, increased respiratory\n effort. Pupils responsive B. Coarse BS B. RRR s1s2 3/6SM 3/4DM. Min BS.\n Peripheral digital necrosis. Labs notable for WBC 18K, HCT 31, PLT 40,\n INR 2.2, K+ 2.7, Cr 1.2, lactate 2.7. Imaging as above.\n Agree with plan to manage massive LGIB in the setting of blood loss\n anemia and DIC following bowel resection in this patient with\n aggressive endocarditis c/b multiorgan failure with ongoing aggressive\n resuscitation - PRBC (HCT goal >30), FFP (INR <1.8) (1:1 ration), plts\n 6 units (PRBC:plt ratio 1:4), cryo, calcium. Case d/w attending\n surgical attending on rounds\n very poor candidate for OR, will reverse\n coagulopathy using rhFV11A and attempt IR embolization, though this\n carries high risk for anasomotic ischemia and breakdown. Underlying\n sepsis / endocarditis - continue vanco to level, cefepime, and flagyl,\n check echo, consult ID and CV surgery. For respiratory failure,\n maintain VAC with goal 6cc/kg, increase PEEP if unable to keep PaO2\n >60. ARF is stable, would pretreat with NAC prior to angio, and RD\n meds. have evolving cerebral edema, will check head CT read now.\n Very poor overall prognosis given 3v endocarditis c/b hypoperfusion and\n massive bleed. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 90 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:40 PM ------\n" }, { "category": "Physician ", "chartdate": "2191-01-31 00:00:00.000", "description": "MICU Attending Event Note", "row_id": 614784, "text": "MICU ATTENDING EVENT NOTE\n Family Meeting / Code / Death\n Case reviewed in detail with patients mother, step father, and brother.\n Critical nature of the situation discussed in waiting room at 1330.\n Called to bedside at 1400 for increased respiratory efforts and falling\n PaO2 in the setting of poor pleth, signs of progressive pulmonary edema\n based on ETT secretions. Increased PEEP to 12 and FiO2 to 1.0, started\n paralytics but unable to move patient to IR d/t increasing secretions\n from ETT and worsening gas exchange. While attempting stabilization,\n and following visit by family at 1445, patient developed bradycardia\n and subsequent PEA arrest. Multiple rounds of ACLS including CPR with\n good art line trace, epi, atropine, HCO3, D50, calcium, and amio as\n well as defib x2 for ?fine VF, though this was likely asystole. Family\n in room throughout 25 minute code. Unable to establish ROSC, code\n called at 1525. Patient anointed by Father during code, situation\n debriefed with ICU team, and then discussed at length with all family\n members as well as SW .\n Patient is critically ill\n Total time: 110 min\n" }, { "category": "Echo", "chartdate": "2191-01-31 00:00:00.000", "description": "Report", "row_id": 88343, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nWeight (lb): 200\nBP (mm Hg): 137/65\nHR (bpm): 119\nStatus: Inpatient\nDate/Time: at 11:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Low normal LVEF. [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.] No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Large vegetation on aortic valve. No AS. Increased transaortic\nvelocity related to increased stroke volume due to AR. Severe (4+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate-sized\nvegetation on mitral valve. Mild thickening of mitral valve chordae. Moderate\nto severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed with the\nhouseofficer caring for the patient. Left pleural effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. Regional left ventricular wall\nmotion is normal. Overall left ventricular systolic function is low normal\n(LVEF 50%). [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.] Right ventricular\nchamber size is normal with moderate global free wall hypokinesis. The\nascending aorta is mildly dilated. There is a large vegetation near replacing\nthe aortic valve leaflets. There is no valvular aortic stenosis. The increased\ntransaortic velocity is likely related to increased stroke volume due to\naortic regurgitation.Severe (4+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. A 0.4 x 1cm vegetation is strongly\nsuggested on the left atrial side of the valve. Moderate to severe (3+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened with\nmild-moderate tricuspid regurgitation. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Large vegetation/replacement of the aortic valve with severe\naortic regurgitation. Probable mitral valve vegetation with moderate to severe\nmitral regurgitation. Pulmonary artery systolic hypertension. Normal left\nventricular cavity size with inappropriate low normal systolic function. Right\nventricular free wall hypokinesis.\n\n\n" }, { "category": "ECG", "chartdate": "2191-01-30 00:00:00.000", "description": "Report", "row_id": 229585, "text": "Sinus tachycardia with ventricular premature beat. Low QRS voltage. Diffuse low\namplitude T wave changes. Findings are non-specific but clinical correlation is\nsuggested. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2191-01-31 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1116015, "text": ", F. MED MICU 12:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval amount of contrast\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with contrast in abdomen s/p CT\n REASON FOR THIS EXAMINATION:\n eval amount of contrast\n ______________________________________________________________________________\n PFI REPORT\n Contrast seen with a non-dilated small bowel.\n\n" }, { "category": "Radiology", "chartdate": "2191-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115916, "text": " 10:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulm pathology, placement of tubes and lines\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with respiratory failure, OSH transfer\n REASON FOR THIS EXAMINATION:\n eval pulm pathology, placement of tubes and lines\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:45 P.M. \n\n HISTORY: Respiratory failure, evaluate pulmonary pathology.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs read\n in conjunction with chest CT :\n\n Mild pulmonary edema is comparable to the appearance on , left\n lower lobe consolidation probably atelectasis, given leftward mediastinal\n shift, has worsened. Small bilateral pleural effusions are presumed. Lines\n and tubes in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-01-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1115953, "text": " 7:46 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with respiratory failure s/p CVL placement\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:20 A.M, 5623\n\n HISTORY: Respiratory failure. Central venous line placement.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the right jugular introducer is at the junction of the brachiocephalic\n veins. There is no pneumothorax, mediastinal widening or new pleural\n effusion. Left lower lobe remains entirely consolidated due to collapse or\n pneumonia. Edema is most pronounced in the perihilar left lung, mild in the\n right lung. Mild cardiomegaly is stable. No pneumothorax. Pleural effusion,\n small on the right and moderate on the left has improved. ET tube is in\n standard placement and a nasogastric tube is traceable to the upper stomach,\n but the tip is indistinct. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-01-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1115986, "text": " 10:35 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please eval position\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with RIJ trauma line placed earlier, running more sluggish at\n this time\n REASON FOR THIS EXAMINATION:\n please eval position\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:50 A.M. \n\n HISTORY: Trauma. Right IJ line.\n\n IMPRESSION: AP chest compared to .\n\n Obscuration of the lower lungs is more pronounced now than earlier in the day\n due to combination of worsening bibasilar consolidation, increasing effusions\n and the development of new interstitial pulmonary edema. Borderline\n cardiomegaly is stable. No pneumothorax. Right jugular line ends at the\n thoracic inlet. Tip of the endotracheal tube is at the upper margin of the\n clavicles, approximately 4 cm above the carina. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-01-31 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1116014, "text": " 12:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval amount of contrast\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with contrast in abdomen s/p CT\n REASON FOR THIS EXAMINATION:\n eval amount of contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa MON 4:29 PM\n Contrast seen with a non-dilated small bowel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for passage of oral contrast from prior CT\n examination.\n\n Single supine view of the abdomen and pelvis demonstrates oral contrast from\n prior CT examination within nondilated loops of small bowel, though difficult\n to assess due to edema and body habitus. No obstructive bowel gas pattern is\n present. An NG tube is in place with tip in the distal stomach. Surgical\n staples within the abdomen are present.\n\n IMPRESSION: Oral contrast within nondilated small bowel.\n\n Further radiographs to assess passage of contrast will likely be limited due\n to continued dilution of contrast, edema and body habitus.\n\n" }, { "category": "Radiology", "chartdate": "2191-01-31 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1115929, "text": " 2:43 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for septic emboli, infiltrate\n Admitting Diagnosis: ENDOCARDITIS\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with endocarditis\n REASON FOR THIS EXAMINATION:\n eval for septic emboli, infiltrate\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;renal failure;renal failure\n ______________________________________________________________________________\n WET READ: JXKc MON 8:49 AM\n CHEST: ET tube tip at carina, should be pulled back. Multifocal ground glass\n and nodular opacities, septic emboli cannot be excluded. Small bilateral\n pleural effusions with consolidation of adjacent lung. ABD/PELVIS: Small\n perihepatic ascites. Multiple intermediate density collections in the spleen,\n presumed sequela of infarction. Hypodensities in left kidney, may reflect\n infarcts. Malrotation of bowel with solitary left kidney. There has been\n interval bowel resection with anastomotic sutures in mid abdomen. Diffuse\n bowel wall thickening of colon and several small bowel loops, with dilation of\n small bowel loops, may relate to anasarca and edema. Irregular endplate\n changes of L5, better assessed on MRI. Left adrenal nodule. -jkang.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old female with endocarditis, evaluate for septic emboli or\n infiltrate.\n\n COMPARISON: CT performed at each .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis without the administration of IV contrast. Oral contrast was\n administered. Coronal and sagittal reformations were obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The heart and pericardium are without\n pericardial effusion. No pathologically enlarged mediastinal, hilar, or\n axillary lymphadenopathy is identified, with paratracheal nodes measuring up\n to 8 mm in short axis. An endotracheal tube is seen, with tip terminating\n just above the carina, and should be pulled back. A small focal outpouching\n of the air along the right posterolateral surface of the trachea most likely\n reflects the tracheal diverticulum.\n\n There are multifocal ground-glass opacities throughout the lungs bilaterally,\n with scattered nodular opacities also seen diffusely bilaterally. The\n findings are concerning for associated septic emboli. Additionally there is\n consolidation of the lower lobes bilaterally, with small pleural effusions.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The liver and pancreas are grossly\n unremarkable, on this limited non-contrast evaluation. High intraluminal\n contents within the gallbladder likely reflect vicarious excretion of contrast\n from prior contrast administration. There are multiple rounded cystic\n (Over)\n\n 2:43 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for septic emboli, infiltrate\n Admitting Diagnosis: ENDOCARDITIS\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hypodensities within the spleen, which likely reflect sequela from splenic\n infarction, and are smaller in size compared to the prior study. The kidneys\n demonstrate subtle striations, on this non-contrast imaging, with additional\n focal hypodensity seen within the lower pole. Areas of renal infarction are\n of concern. The right kidney is absent. There is a slight nodular thickening\n at the left adrenal gland, which is incompletely characterized.\n\n Nasogastric tube is in stomach. There is a note made of complete malrotation\n of the small bowel, with small bowel loops located to the right of the\n abdomen. There is diffuse bowel wall edema involving small and large bowel\n loops, no obstruction is identified. Anastomotic sutures are seen within the\n bowel loop within the mid abdomen. Bowel ischemia cannot be excluded, without\n intravenous contrast.\n\n There is a small amount of perihepatic ascites. No pathologically enlarged\n mesenteric or retroperitoneal lymphadenopathy is identified.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Right femoral line is visualized.\n Foley catheter is in bladder. The rectum and uterus are unremarkable. A\n small amount of free fluid is seen within the pelvis.\n\n OSSEOUS STRUCTURES: There is a slight cortical irregularity involving the\n inferior endplate of L4 and the superior endplate of L5, as well as the\n inferior endplate of L5. It is unclear whether this represents degenerative\n change or underlying discitis/osteomyelitis. Midline surgical staples are\n noted.\n\n IMPRESSION:\n 1. Multifocal ground-glass and nodular opacities throughout the lungs, may be\n infectious or inflammatory, and septic emboli is of concern.\n 2. Endotracheal tube tip at the level of carina, and should be slightly\n withdrawn.\n 3. Multiple hypodensities in the spleen, likely represent sequela of\n infarction.\n 4. Subtle hypodensities throughout the left kidney, suspicious for renal\n infarcts.\n 5. Diffuse bowel wall edema involving small and large bowel loops, may relate\n to anasarca and edema. Evaluation for ischemia is limited without intravenous\n contrast.\n 6. Irregular endplate changes of L4 and L5 vertebral bodies, which may be\n degenerative. However underlying discitis or osteomyelitis cannot be entirely\n excluded.\n (Over)\n\n 2:43 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for septic emboli, infiltrate\n Admitting Diagnosis: ENDOCARDITIS\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2191-01-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1115928, "text": " 2:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for evidence of emboli, bleed, explanation of delta MS\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with endocarditis, altered mental status\n REASON FOR THIS EXAMINATION:\n eval for evidence of emboli, bleed, explanation of delta MS\n contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc MON 5:18 AM\n No acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old female with endocarditis, altered mental status.\n Evaluate for evidence of emboli, bleed, or other explanation of altered mental\n status.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, shift of\n normally midline structures, or infarction. The ventricles and sulci are\n normal in size and configuration. There is an air-fluid level within the\n right sphenoid sinus and right maxillary sinus, with secretions also seen\n within the nasopharynx, which may relate to intubation.\n\n IMPRESSION: No acute intracranial process.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2138-03-26 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 404812, "text": "Chief Complaint: weakness, diarrhea\n HPI:\n The patient is a 76 yoM with an extensive past medical history\n including type A aortic dissection in s/p aortic arch replacement,\n CABG x 1, re-operation for dilated thoracic aorta in with a very\n complicated post-op course, PAF on coumadin, PAD, diastolic CHF, HTN\n and recent C diff presents with weakness and diarrhea. The patient has\n had recurrent C diff. He had C diff initially around , and he had\n recurrent diarrhea at the end of - C diff x 3 were negative at\n rehab but he was treated with PO flagyl x 14 days empirically. His\n symptoms resolved with flagyl. He was discharged from rehab to home on\n and he stopped flagyl . After a few days his diarrhea\n returned, at first it was just unformed but slowly progressed to watery\n diarrhea. His diarrhea acutely worsened over the past 24 hours- he had\n 8 large watery BMs over this time period. He has some mild lower\n abdominal pain, urinary urgency and dysuria x 3 days. No nausea or\n vomiting. No flank pain, no F/C. He has had a 30 pound weight loss\n over the past few months.\n + cough productive of clear sputum. No CP, SOB or other symptoms.\n In the ER initial VS were: T 98.2 HR 60 BP 95/47 O2 sat: 96% RA. He\n rec'd 500mg po flagyl x 1 in the ER. He had hypotension to a systolic\n 70 while in the ER which improved to systolic 90s after 4 liters of\n IVF. Prior to transfer VS were: T 98.2 Afib 100-115 BP 103/57 95%\n on RA.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Amiodarone\n hyperthryoidism\n Monosodium Glutamate\n violent headach\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Aspirin 81 mg po daily\n Warfarin 6 mg po daily\n Dronedarone 400 mg po bid\n Phenytoin 100mg po tid\n Keppra 1000mg po bid\n Metoprolol Tartrate 50 mg po tid\n Simvastatin 10 mg po daily\n atrovent / albuterol prn\n Bisacodyl 10mg po daily\n Docusate Sodium 50 mg/5, 10mL po bid\n Senna 8.6 mg po bid\n Acetaminophen prn\n Ranitidine HCl 150 mg po daily\n Past medical history:\n Family history:\n Social History:\n Type A aortic dissection in s/p replacement aortic arch,\n resuspension of aortic valve, coronary artery bypass graft x1\n s/p coil embolization of his left internal iliac aneurysm \n CTA in showed increase in size of aorta to 6.3cm,\n hence underwent planned redo repair in with\n replacement of ascending aorta and arch with graft\n - developed seizures post-op, neurology felt this was sign of\n anoxic cerebral insult\n - found to have E faecalis bacteremia\n - LLL PNA with Cx growing serratia and E Coli\n - left chest tube placed for pleural effusion\n - right IJ thrombosis found during line placement\n - hematuria felt to be due to Foley trauma while on coumadin;\n required CBI and followed by urology\n - had trach and GJ tube \n - underwent work-up with bronch for possible TBM, which was\n negative\n - slow neurologic improvement, at time of discharge:\n \"he was able to follow commands- he was able to open his eyes,\n grasp my fingers, and stick out his tongue. He was not moving\n his limbs other than moving his toes and fingers and was not\n antigravity, he was\n areflexic\"\n - dc'd to rehab on trach collar with CPAP\n Readmitted with fever and seizures\n - coag negative staph bacteremia from PICC line\n - found to have Cholecystitis but not felt to be operative\n candidate, so had percutaneous choleycystostomy tube\n - left subclavian DVT noted \n - dc'd back to rehab with plan for 6 weeks of vancomycin and\n return in months for cholecystectomy\n pAFib s/p ablation , on coumadin\n s/p PPM for tachy-brady syndrome\n HTN\n Hyperlipidemia\n PVD\n Anemia, felt to be due to chronic disease\n h/o CHF with preserved EF\n Diverticulosis\n Benign prostatic hyperplasia\n Spinal Stenosis\n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Was living at rehab- came home and living w/ his wife\n since . smoker, but quit. Married, wife is his HCP.\n Review of systems:\n Flowsheet Data as of 09:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 115 (115 - 127) bpm\n BP: 98/69(75) {98/69(75) - 98/69(75)} mmHg\n RR: 21 (21 - 31) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 14 mL\n PO:\n TF:\n IVF:\n 14 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -346 mL\n Respiratory\n SpO2: 94%\n Physical Examination\n Vitals - T: 99.0 BP: 88/50 HR: 111 RR: 19 02 sat: 98% on RA\n GENERAL: NAD, AOX3\n HEENT: JVP 7cm while at 15 degrees, MM dry, EOMI, PERRL, sclera\n anicteric, conjunctiva pink\n CARDIAC: RRR, no m/r/g\n LUNG: Rales at L base\n ABDOMEN: soft, NT, ND, no masses or organomegaly, BS+\n EXT: WWP, no c/c/e\n NEURO: AOx3, moving all extremities, resting tremor of L arm\n (baseline)\n Labs / Radiology\n 207\n 102\n 1.7\n 41\n 23\n 106\n 3.7\n 141\n 35\n 12.1\n [image002.jpg]\n INR 2.0\n Imaging: : KUB (final read) Non-specific bowel gas pattern. No\n free intraperitoneal air.\n CXR: Decrease in size of left pleural effusion from prior\n examination. Small residual remaining. Also of note, not mentioned\n above, a right upper extremity PICC line has been removed in the\n interval. Otherwise, stable exam with no definite acute pulmonary\n process.\n Microbiology: stool culture pending\n blood culture pending\n ECG: ECG: afib rate of 111, horizontal axis, RBBB, no ST T\n changes, no Q waves.\n Assessment and Plan\n The patient is a 76yoM w/ a h/o aortic dissection s/p aortic arch\n replacement in and reoperation in , with recent C diff,\n stopped flagyl and had recurrent diarrhea.\n # C diff: will start vancomycin PO and flagyl IV for now. Seems to\n have failed PO flagyl alone. Will eventually have a long taper of PO\n vancomycin and initiation of probiotics at the end of taper.\n -PO vanc / IV flagyl\n -f/u KUB final read\n -IVF bolus 1L for hypovolemia\n # Afib with RVR: on dronedarone in the past, per wife no longer on this\n medication but she will bring in his med list in the a.m. Normal EF as\n of . At this point the patient appears hypovolemic. Will fluid\n replete first then start lopressor at a low dose and uptitrate to home\n regimen.\n -IVF, when euvolemic will start lopressor\n -continue coumadin at 4mg daily given concurrent abx\n # UTI: has a + u/a and dysuria.\n -treat with bactrim for limited course\n -f/u urine culture\n # seizure d/o: continue dilantin and keppra per dosing of recent neuro\n note, confirm w/ wife's med list in a.m.\n # CKD: baseline Cr 1.7 since , prior to this was normal. Continue\n to monitor with fluid repletion.\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: Home H2 blocker prn, coumadin, bowel regimen\n # ACCESS: PIV\n # CODE: FULL\n # CONTACT: Wife\n # ICU CONSENT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:26 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 76M type A dissection s/p arch replacement\n , redo with prolonged HC in CVICU c/b c. diff p/w progressive\n watery diarrhea. In ED, developed hypotension requiring 4L AF but no\n pressors as well as AF c RVR.\n Exam notable for Tm BP 90/50 HR 60 RR 18 with sat 97 on 2LNC. Frail\n man, NAD. JVD flat. RRR s1s2 2/6SM. CTA B. Soft +BS. No edema. Labs\n notable for WBC 12K, HCT 34, K+ 3.7, Cr 1.7, lactate 1.9. CXR with\n clear lungs, L effusion, KUB ? colis LLQ, UA +, EKG AF 111 RB3.\n Agree with plan to manage hypotension in the setting of likely volume\n depletion, recurrent c. diff and AF c RVR with volume resuscitation,\n flagyl IV / vanco PO with long taper and probiotics, recheck c. diff\n toxin assay. AF c RVR improved with volume, hold nodal agents for now,\n low dose BBL in AM as able. For UTI, will treat with CTX and f/u cx\n result. Sz well controlled on current regimen. CRI - baseline, monitor\n with IVF, RD meds. AF - BBL as able, coumadin tomorrow. Remainder of\n plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:50 ------\n" }, { "category": "Nursing", "chartdate": "2138-03-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 404879, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n + UTI noted. Ceftriaxone initiated, foley removed @ 12MD [\n borderline U/O overnight 30-40cc/hr]\n Wife HCP and visited/updated\n PIV x 2. Full Code\n EVENTS\nstill require x2 stool specimens for cdif\n Taking PO diet\n Stable, C/O\n Atrial fibrillation (Afib)\n Assessment:\n Previous outbursts of AF in ED but reverted to SR overnight, received\n rate 60-65bpm Minimal PVC\ns noted. Pt does have pacemaker to Rt chest\n wall. SBP 90-120 Dry mucous membranes noted. U/O 30-40cc/hr, being TX\n for UTI on ceftriazone\n Action:\n Maintained SR and re-ordered for low dose BBlockers [ with params],\n team requested [ despite borderline U/O] to have foley removed,\n encourage PO intake\n Response:\n SR 60-65 bpm bp 110-120 systolic. Pt denies HA/CP/SOB, not yet passed\n urine and foley was removed @ 1200hrs\n Plan:\n Cont to monitor HR and SBP. Ensure patient has passed urine\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Received pt w/ current diagnosis of Cdiff (last course finished )\n Pt did have 1 golden/mucous stool on arrival but non since. Tmax 97 WBC\n this AM 9.9\n Action:\n 1^st stool culture has come back + for Cdiff. (pt will need stool cx 2\n & 3) Flagyl IV & Vanco PO continues\n Response:\n No active stool today.\n Plan:\n Cont to monitor a stool output. Cont Flagyl & Vanco @ this time\n Problem - Description In Comments\n Assessment:\n Patient has at baseline tremor to left arm/leg for which the neuro team\n follow [Dr ], ? more prominent at this time\n Action:\n Takes keppra/ dilantin, await neuro review\n Response:\n Stable at this time\n Plan:\n Await neuro review\n ------ Protected Section ------\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n DEHYDRATION/ WEAKNESS\n Code status:\n Full code\n Height:\n Admission weight:\n 86.2 kg\n Daily weight:\n Allergies/Reactions:\n Amiodarone\n hyperthryoidism\n Monosodium Glutamate\n violent headach\n Precautions: Contact\n PMH: Anemia, Seizures\n CV-PMH: Arrhythmias, CAD, Hypertension, PVD\n Additional history: Paroxysmal Afib s/p ablation , Type A aortic\n dissection in 04, s/p aortic arch replacement, resuspension of aortic\n valve, CABG x1 , s/p coil embolization of left internal iliac\n aneurysm (sz's post op - neuro felt sign of anoxic cerebral\n insult), E faecalis bacteremia, LLL PNA w/ serratia & e.coli (left CT\n for pleural effusion), R IJ thrombus (found during line placement,\n Hematura requiring CBI, Trach & GJ tube , , staph\n bacteremia from picc line, cholysistitis (not operative candidate) perc\n cholycystostomy, left sc dvt , hx of CHF w/ preserved EF,\n Diverticulosis, BPH, Spinal Stenosis\n Surgery / Procedure and date: CABG, s/p pacemaker, aortic valve\n resuspension, replacement of aortic arch\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:108\n D:45\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,747 mL\n 24h total out:\n 460 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:45 AM\n Potassium:\n 3.3 mEq/L\n 04:45 AM\n Chloride:\n 111 mEq/L\n 04:45 AM\n CO2:\n 22 mEq/L\n 04:45 AM\n BUN:\n 32 mg/dL\n 04:45 AM\n Creatinine:\n 1.3 mg/dL\n 04:45 AM\n Glucose:\n 91 mg/dL\n 04:45 AM\n Hematocrit:\n 33.8 %\n 04:45 AM\n Additional pertinent labs:\n k repleted with 40 PO and mag repleted with 2g IV\n Lines / Tubes / Drains:\n x2 pivs \n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 7\n Transferred to: 2\n Date & time of Transfer: 12:00 AM\n ------ Protected Section Addendum Entered By: , RN\n on: 14:46 ------\n" }, { "category": "Nursing", "chartdate": "2138-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 404806, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2138-03-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 404877, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n + UTI noted. Ceftriaxone initiated, foley removed @ 12MD [\n borderline U/O overnight 30-40cc/hr]\n Wife HCP and visited/updated\n PIV x 2. Full Code\n EVENTS\nstill require x2 stool specimens for cdif\n Taking PO diet\n Stable, C/O\n Atrial fibrillation (Afib)\n Assessment:\n Previous outbursts of AF in ED but reverted to SR overnight, received\n rate 60-65bpm Minimal PVC\ns noted. Pt does have pacemaker to Rt chest\n wall. SBP 90-120 Dry mucous membranes noted. U/O 30-40cc/hr, being TX\n for UTI on ceftriazone\n Action:\n Maintained SR and re-ordered for low dose BBlockers [ with params],\n team requested [ despite borderline U/O] to have foley removed,\n encourage PO intake\n Response:\n SR 60-65 bpm bp 110-120 systolic. Pt denies HA/CP/SOB, not yet passed\n urine and foley was removed @ 1200hrs\n Plan:\n Cont to monitor HR and SBP. Ensure patient has passed urine\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Received pt w/ current diagnosis of Cdiff (last course finished )\n Pt did have 1 golden/mucous stool on arrival but non since. Tmax 97 WBC\n this AM 9.9\n Action:\n 1^st stool culture has come back + for Cdiff. (pt will need stool cx 2\n & 3) Flagyl IV & Vanco PO continues\n Response:\n No active stool today.\n Plan:\n Cont to monitor a stool output. Cont Flagyl & Vanco @ this time\n Problem - Description In Comments\n Assessment:\n Patient has at baseline tremor to left arm/leg for which the neuro team\n follow [Dr ], ? more prominent at this time\n Action:\n Takes keppra/ dilantin, await neuro review\n Response:\n Stable at this time\n Plan:\n Await neuro review\n" }, { "category": "Physician ", "chartdate": "2138-03-25 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 404801, "text": "Chief Complaint: weakness, diarrhea\n HPI:\n The patient is a 76 yoM with an extensive past medical history\n including type A aortic dissection in s/p aortic arch replacement,\n CABG x 1, re-operation for dilated thoracic aorta in with a very\n complicated post-op course, PAF on coumadin, PAD, diastolic CHF, HTN\n and recent C diff presents with weakness and diarrhea. The patient has\n had recurrent C diff. He had C diff initially around , and he had\n recurrent diarrhea at the end of - C diff x 3 were negative at\n rehab but he was treated with PO flagyl x 14 days empirically. His\n symptoms resolved with flagyl. He was discharged from rehab to home on\n and he stopped flagyl . After a few days his diarrhea\n returned, at first it was just unformed but slowly progressed to watery\n diarrhea. His diarrhea acutely worsened over the past 24 hours- he had\n 8 large watery BMs over this time period. He has some mild lower\n abdominal pain, urinary urgency and dysuria x 3 days. No nausea or\n vomiting. No flank pain, no F/C. He has had a 30 pound weight loss\n over the past few months.\n + cough productive of clear sputum. No CP, SOB or other symptoms.\n In the ER initial VS were: T 98.2 HR 60 BP 95/47 O2 sat: 96% RA. He\n rec'd 500mg po flagyl x 1 in the ER. He had hypotension to a systolic\n 70 while in the ER which improved to systolic 90s after 4 liters of\n IVF. Prior to transfer VS were: T 98.2 Afib 100-115 BP 103/57 95%\n on RA.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Amiodarone\n hyperthryoidism\n Monosodium Glutamate\n violent headach\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Aspirin 81 mg po daily\n Warfarin 6 mg po daily\n Dronedarone 400 mg po bid\n Phenytoin 100mg po tid\n Keppra 1000mg po bid\n Metoprolol Tartrate 50 mg po tid\n Simvastatin 10 mg po daily\n atrovent / albuterol prn\n Bisacodyl 10mg po daily\n Docusate Sodium 50 mg/5, 10mL po bid\n Senna 8.6 mg po bid\n Acetaminophen prn\n Ranitidine HCl 150 mg po daily\n Past medical history:\n Family history:\n Social History:\n Type A aortic dissection in s/p replacement aortic arch,\n resuspension of aortic valve, coronary artery bypass graft x1\n s/p coil embolization of his left internal iliac aneurysm \n CTA in showed increase in size of aorta to 6.3cm,\n hence underwent planned redo repair in with\n replacement of ascending aorta and arch with graft\n - developed seizures post-op, neurology felt this was sign of\n anoxic cerebral insult\n - found to have E faecalis bacteremia\n - LLL PNA with Cx growing serratia and E Coli\n - left chest tube placed for pleural effusion\n - right IJ thrombosis found during line placement\n - hematuria felt to be due to Foley trauma while on coumadin;\n required CBI and followed by urology\n - had trach and GJ tube \n - underwent work-up with bronch for possible TBM, which was\n negative\n - slow neurologic improvement, at time of discharge:\n \"he was able to follow commands- he was able to open his eyes,\n grasp my fingers, and stick out his tongue. He was not moving\n his limbs other than moving his toes and fingers and was not\n antigravity, he was\n areflexic\"\n - dc'd to rehab on trach collar with CPAP\n Readmitted with fever and seizures\n - coag negative staph bacteremia from PICC line\n - found to have Cholecystitis but not felt to be operative\n candidate, so had percutaneous choleycystostomy tube\n - left subclavian DVT noted \n - dc'd back to rehab with plan for 6 weeks of vancomycin and\n return in months for cholecystectomy\n pAFib s/p ablation , on coumadin\n s/p PPM for tachy-brady syndrome\n HTN\n Hyperlipidemia\n PVD\n Anemia, felt to be due to chronic disease\n h/o CHF with preserved EF\n Diverticulosis\n Benign prostatic hyperplasia\n Spinal Stenosis\n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Was living at rehab- came home and living w/ his wife\n since . smoker, but quit. Married, wife is his HCP.\n Review of systems:\n Flowsheet Data as of 09:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 115 (115 - 127) bpm\n BP: 98/69(75) {98/69(75) - 98/69(75)} mmHg\n RR: 21 (21 - 31) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 14 mL\n PO:\n TF:\n IVF:\n 14 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -346 mL\n Respiratory\n SpO2: 94%\n Physical Examination\n Vitals - T: 99.0 BP: 88/50 HR: 111 RR: 19 02 sat: 98% on RA\n GENERAL: NAD, AOX3\n HEENT: JVP 7cm while at 15 degrees, MM dry, EOMI, PERRL, sclera\n anicteric, conjunctiva pink\n CARDIAC: RRR, no m/r/g\n LUNG: Rales at L base\n ABDOMEN: soft, NT, ND, no masses or organomegaly, BS+\n EXT: WWP, no c/c/e\n NEURO: AOx3, moving all extremities, resting tremor of L arm\n (baseline)\n Labs / Radiology\n 207\n 102\n 1.7\n 41\n 23\n 106\n 3.7\n 141\n 35\n 12.1\n [image002.jpg]\n INR 2.0\n Imaging: : KUB (final read) Non-specific bowel gas pattern. No\n free intraperitoneal air.\n CXR: Decrease in size of left pleural effusion from prior\n examination. Small residual remaining. Also of note, not mentioned\n above, a right upper extremity PICC line has been removed in the\n interval. Otherwise, stable exam with no definite acute pulmonary\n process.\n Microbiology: stool culture pending\n blood culture pending\n ECG: ECG: afib rate of 111, horizontal axis, RBBB, no ST T\n changes, no Q waves.\n Assessment and Plan\n The patient is a 76yoM w/ a h/o aortic dissection s/p aortic arch\n replacement in and reoperation in , with recent C diff,\n stopped flagyl and had recurrent diarrhea.\n # C diff: will start vancomycin PO and flagyl IV for now. Seems to\n have failed PO flagyl alone. Will eventually have a long taper of PO\n vancomycin and initiation of probiotics at the end of taper.\n -PO vanc / IV flagyl\n -f/u KUB final read\n -IVF bolus 1L for hypovolemia\n # Afib with RVR: on dronedarone in the past, per wife no longer on this\n medication but she will bring in his med list in the a.m. Normal EF as\n of . At this point the patient appears hypovolemic. Will fluid\n replete first then start lopressor at a low dose and uptitrate to home\n regimen.\n -IVF, when euvolemic will start lopressor\n -continue coumadin at 4mg daily given concurrent abx\n # UTI: has a + u/a and dysuria.\n -treat with bactrim for limited course\n -f/u urine culture\n # seizure d/o: continue dilantin and keppra per dosing of recent neuro\n note, confirm w/ wife's med list in a.m.\n # CKD: baseline Cr 1.7 since , prior to this was normal. Continue\n to monitor with fluid repletion.\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: Home H2 blocker prn, coumadin, bowel regimen\n # ACCESS: PIV\n # CODE: FULL\n # CONTACT: Wife\n # ICU CONSENT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:26 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2138-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 404805, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n" }, { "category": "Physician ", "chartdate": "2138-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 404862, "text": "Chief Complaint:\n 24 Hour Events:\n C diff returned positive\n Allergies:\n Amiodarone\n hyperthryoidism\n Monosodium Glutamate\n violent headach\n Last dose of Antibiotics:\n Metronidazole - 02:10 AM\n Ceftriaxone - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.6\nC (96\n HR: 70 (60 - 127) bpm\n BP: 121/56(75) {88/44(56) - 121/80(87)} mmHg\n RR: 18 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,395 mL\n 1,172 mL\n PO:\n 360 mL\n 400 mL\n TF:\n IVF:\n 1,035 mL\n 772 mL\n Blood products:\n Total out:\n 520 mL\n 370 mL\n Urine:\n 520 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,875 mL\n 802 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP 7cm while at 15 degrees, MM dry, EOMI, PERRL, sclera\n anicteric, conjunctiva pink\n CARDIAC: RRR, no m/r/g\n LUNG: Rales at L base\n ABDOMEN: soft, NT, mild distension\n EXT: WWP, no c/c/e\n NEURO: AOx3, moving all extremities, resting tremor of L arm\n (baseline)\n Labs / Radiology\n 166 K/uL\n 11.2 g/dL\n 91 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 32 mg/dL\n 111 mEq/L\n 141 mEq/L\n 33.8 %\n 9.9 K/uL\n [image002.jpg]\n 04:45 AM\n WBC\n 9.9\n Hct\n 33.8\n Plt\n 166\n Cr\n 1.3\n Glucose\n 91\n Other labs: Ca++:8.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n The patient is a 76yoM w/ a h/o aortic dissection s/p aortic arch\n replacement in and reoperation in , with recent C diff,\n stopped flagyl and had recurrent diarrhea.\n # C diff:\n -PO vanc, no evidence of ileus, d/c IV flagyl\n -serial abdominal exam\n -long PO vanc taper and start probiotics after treatment is finished\n -curbside ID re: follow up\n # Afib with RVR:\n -start lopressor 12.5mg po tid\n -currently sinus, monitor on tele\n -close to euvolemic, slightly hypovolemic, encourage PO\n -continue coumadin at 4mg daily given concurrent abx\n # UTI: has a + u/a and dysuria.\n -f/u culture\n -ceftriaxone\n -remove foley\n # seizure d/o: continue dilantin and keppra per dosing of recent neuro\n note, confirm w/ wife's med list in a.m.\n # CKD: Cr improved to 1.3, continue to monitor\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: Home H2 blocker prn, coumadin, bowel regimen\n # ACCESS: PIV\n # CODE: FULL\n # CONTACT: Wife\n # ICU CONSENT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:26 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2138-03-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 404868, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt from ED in Afib 90-120\ns w/ occasional bursts to 130\n Minimal PVC\ns noted. Pt does have pacemaker to Rt chest wall. SBP\n 80-100\ns. Dry mucous membranes noted.\n Action:\n 1.5 L LR given. Foley catheter placed on arrival. UOP > 30 cc/hr.\n Response:\n Pt has converted to SR 60-62 bpm. Pt denies HA/CP/SOB\n Plan:\n Cont to monitor HR and SBP. Consider additional IV fluids if warranted.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Received pt w/ current diagnosis of Cdiff (last course finished )\n Pt did have 1 golden/mucous stool on arrival. Tmax 99.2. WBC this AM\n 9.9\n Action:\n 1^st stool culture has come back + for Cdiff. (pt will need stool cx 2\n & 3) Flagyl IV & Vanco PO initiated.\n Response:\n No active stool overnight. WBC\n Plan:\n Cont to monitor a stool output. Cont Flagyl & Vanco @ this time\n + UTI noted. Ceftriaxone initiated\n Pt will be called out to floor today\n Wife updated last evening by this RN and Dr \n x 2. Full Code\n" }, { "category": "Nursing", "chartdate": "2138-03-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 404870, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt from ED in Afib 90-120\ns w/ occasional bursts to 130\n Minimal PVC\ns noted. Pt does have pacemaker to Rt chest wall. SBP\n 80-100\ns. Dry mucous membranes noted.\n Action:\n 1.5 L LR given. Foley catheter placed on arrival. UOP > 30 cc/hr.\n Response:\n Pt has converted to SR 60-62 bpm. Pt denies HA/CP/SOB\n Plan:\n Cont to monitor HR and SBP. Consider additional IV fluids if warranted.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Received pt w/ current diagnosis of Cdiff (last course finished )\n Pt did have 1 golden/mucous stool on arrival. Tmax 99.2. WBC this AM\n 9.9\n Action:\n 1^st stool culture has come back + for Cdiff. (pt will need stool cx 2\n & 3) Flagyl IV & Vanco PO initiated.\n Response:\n No active stool overnight. WBC\n Plan:\n Cont to monitor a stool output. Cont Flagyl & Vanco @ this time\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n + UTI noted. Ceftriaxone initiated, foley removed @ 12MD [\n borderline U/O overnight 30-40cc/hr]\n Wife HCP\n x 2. Full Code\n" }, { "category": "Physician ", "chartdate": "2138-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 404857, "text": "Chief Complaint:\n 24 Hour Events:\n C diff returned positive\n Allergies:\n Amiodarone\n hyperthryoidism\n Monosodium Glutamate\n violent headach\n Last dose of Antibiotics:\n Metronidazole - 02:10 AM\n Ceftriaxone - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.6\nC (96\n HR: 70 (60 - 127) bpm\n BP: 121/56(75) {88/44(56) - 121/80(87)} mmHg\n RR: 18 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,395 mL\n 1,172 mL\n PO:\n 360 mL\n 400 mL\n TF:\n IVF:\n 1,035 mL\n 772 mL\n Blood products:\n Total out:\n 520 mL\n 370 mL\n Urine:\n 520 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,875 mL\n 802 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 166 K/uL\n 11.2 g/dL\n 91 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 32 mg/dL\n 111 mEq/L\n 141 mEq/L\n 33.8 %\n 9.9 K/uL\n [image002.jpg]\n 04:45 AM\n WBC\n 9.9\n Hct\n 33.8\n Plt\n 166\n Cr\n 1.3\n Glucose\n 91\n Other labs: Ca++:8.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n The patient is a 76yoM w/ a h/o aortic dissection s/p aortic arch\n replacement in and reoperation in , with recent C diff,\n stopped flagyl and had recurrent diarrhea.\n # C diff: will start vancomycin PO and flagyl IV for now. Seems to\n have failed PO flagyl alone. Will eventually have a long taper of PO\n vancomycin and initiation of probiotics at the end of taper.\n -PO vanc / IV flagyl\n -f/u KUB final read\n -IVF bolus 1L for hypovolemia\n # Afib with RVR: on dronedarone in the past, per wife no longer on this\n medication but she will bring in his med list in the a.m. Normal EF as\n of . At this point the patient appears hypovolemic. Will fluid\n replete first then start lopressor at a low dose and uptitrate to home\n regimen.\n -IVF, when euvolemic will start lopressor\n -continue coumadin at 4mg daily given concurrent abx\n # UTI: has a + u/a and dysuria.\n -treat with bactrim for limited course\n -f/u urine culture\n # seizure d/o: continue dilantin and keppra per dosing of recent neuro\n note, confirm w/ wife's med list in a.m.\n # CKD: baseline Cr 1.7 since , prior to this was normal. Continue\n to monitor with fluid repletion.\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: Home H2 blocker prn, coumadin, bowel regimen\n # ACCESS: PIV\n # CODE: FULL\n # CONTACT: Wife\n # ICU CONSENT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:26 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2138-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 404835, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt from ED in Afib 90-120\ns w/ occasional bursts to 130\n Minimal PVC\ns noted. Pt does have pacemaker to Rt chest wall. SBP\n 80-100\ns. Dry mucous membranes noted.\n Action:\n 1.5 L LR given. Foley catheter placed on arrival. UOP > 30 cc/hr.\n Response:\n Pt has converted to SR 60-62 bpm. Pt denies HA/CP/SOB\n Plan:\n Cont to monitor HR and SBP. Consider additional IV fluids if warranted.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Received pt w/ current diagnosis of Cdiff (last course finished )\n Pt did have 1 golden/mucous stool on arrival. Tmax 99.2. WBC this AM\n 9.9\n Action:\n 1^st stool culture has come back + for Cdiff. (pt will need stool cx 2\n & 3) Flagyl IV & Vanco PO initiated.\n Response:\n No active stool overnight. WBC\n Plan:\n Cont to monitor a stool output. Cont Flagyl & Vanco @ this time\n + UTI noted. Ceftriaxone initiated\n Pt will be called out to floor today\n Wife updated last evening by this RN and Dr \n x 2. Full Code\n" }, { "category": "ECG", "chartdate": "2138-03-25 00:00:00.000", "description": "Report", "row_id": 298219, "text": "Atrial fibrillation with rapid ventricular response. Right bundle-branch block.\nEarly beat may be ventricular or aberration. Since the previous tracing\nof the rhythm is now atrial fibrillation and there is no ventricular\npacing artifact seen.\n\n" }, { "category": "Nursing", "chartdate": "2138-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 404826, "text": "76 yo M with an extensive PMH including type A aortic dissection in\n s/p aortic arch replacement, CABG x 1, re-operation for dilated\n thoracic aorta in with a very complicated post-op course. Hx of\n PAF on Coumadin, PAD, dCHF, HTN and recent C diff who presents with\n weakness and diarrhea. He had C diff initially around , and he had\n recurrent diarrhea at the end of . C diff x 3 were negative at\n rehab but he was treated with PO Flagyl x 14 days empirically. He was\n discharged from rehab to home on and he stopped Flagyl .\n After a few days, his diarrhea returned & has acutely worsened over the\n past 24 hours (~ 8 large watery BMs over this time period) He has some\n mild lower abdominal pain, urinary urgency and dysuria x 3 days. No\n nausea or vomiting. No flank pain, no F/C. He has had a 30 pound\n weight loss over the past few months.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt from ED in Afib 90-120\ns w/ occasional bursts to 130\n Minimal PVC\ns noted. Pt does have pacemaker to Rt chest wall. SBP\n 80-100\ns. Dry mucous membranes noted.\n Action:\n 1.5 L LR given. Foley catheter placed on arrival. UOP > 30 cc/hr.\n Response:\n Pt has converted to SR 60-62 bpm. Pt denies HA/CP/SOB\n Plan:\n Cont to monitor HR and SBP. Consider additional IV fluids if warranted.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Received pt w/ current diagnosis of Cdiff (last course finished )\n Pt did have 1 golden/mucous stool on arrival. Tmax 99.2. WBC this AM\n 9.9\n Action:\n 1^st stool culture has come back + for Cdiff. (pt will need stool cx 2\n & 3) Flagyl IV & Vanco PO initiated.\n Response:\n No active stool overnight. WBC\n Plan:\n Cont to monitor a stool output. Cont Flagyl & Vanco @ this time\n + UTI noted. Ceftriaxone initiated\n Pt will be called out to floor today\n Wife updated last evening by this RN and Dr \n x 2. Full Code\n" }, { "category": "Physician ", "chartdate": "2138-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 404898, "text": "Chief Complaint:\n 24 Hour Events:\n C diff returned positive\n Allergies:\n Amiodarone\n hyperthryoidism\n Monosodium Glutamate\n violent headach\n Last dose of Antibiotics:\n Metronidazole - 02:10 AM\n Ceftriaxone - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.6\nC (96\n HR: 70 (60 - 127) bpm\n BP: 121/56(75) {88/44(56) - 121/80(87)} mmHg\n RR: 18 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,395 mL\n 1,172 mL\n PO:\n 360 mL\n 400 mL\n TF:\n IVF:\n 1,035 mL\n 772 mL\n Blood products:\n Total out:\n 520 mL\n 370 mL\n Urine:\n 520 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,875 mL\n 802 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP 7cm while at 15 degrees, MM dry, EOMI, PERRL, sclera\n anicteric, conjunctiva pink\n CARDIAC: RRR, no m/r/g\n LUNG: Rales at L base\n ABDOMEN: soft, NT, mild distension\n EXT: WWP, no c/c/e\n NEURO: AOx3, moving all extremities, resting tremor of L arm\n (baseline)\n Labs / Radiology\n 166 K/uL\n 11.2 g/dL\n 91 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 32 mg/dL\n 111 mEq/L\n 141 mEq/L\n 33.8 %\n 9.9 K/uL\n [image002.jpg]\n 04:45 AM\n WBC\n 9.9\n Hct\n 33.8\n Plt\n 166\n Cr\n 1.3\n Glucose\n 91\n Other labs: Ca++:8.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n The patient is a 76yoM w/ a h/o aortic dissection s/p aortic arch\n replacement in and reoperation in , with recent C diff,\n stopped flagyl and had recurrent diarrhea.\n # C diff:\n -PO vanc, no evidence of ileus, d/c IV flagyl\n -serial abdominal exam\n -long PO vanc taper and start probiotics after treatment is finished\n -curbside ID re: follow up\n # Afib with RVR:\n -start lopressor 12.5mg po tid\n -currently sinus, monitor on tele\n -close to euvolemic, slightly hypovolemic, encourage PO\n -continue coumadin at 4mg daily given concurrent abx\n # UTI: has a + u/a and dysuria.\n -f/u culture\n -ceftriaxone\n -remove foley\n # seizure d/o: continue dilantin and keppra per dosing of recent neuro\n note, confirm w/ wife's med list in a.m.\n # CKD: Cr improved to 1.3, continue to monitor\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: Home H2 blocker prn, coumadin, bowel regimen\n # ACCESS: PIV\n # CODE: FULL\n # CONTACT: Wife\n # ICU CONSENT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:26 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I have seen and examined the patient with the resident and agree\n substantially with the assessment and plan with the following\n emphasis/modifications:\n Overnight, blood pressure and heart rate remained stable and he feels\n much improved\n T 37 P 70 BP 120/56 RR 18 SaO2: 96%\n General: Awake, alert NAD\n Chest: CTA bilaterally\n Heart: S1 S2 reg\n Abd: Soft NT ND\n Ext: no edema\n Labs\n reviewed and as above\n Assessment:\n 1) Clostridium Dificile\n 2) Atrial Fibrillation\n 3) UTI\n 4) Seizure disorder\n Plan:\n 1) Continue flagyl IV/vanc PO\n 2) continue to advance diet\n 3) Start lopressor\n 4) Transfer to floor\n Time Spent: 25 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 05:04 PM ------\n" } ]

[ { "category": "Nursing/other", "chartdate": "2111-02-10 00:00:00.000", "description": "Report", "row_id": 1337462, "text": " \"B\" Nsg Progress Note:\n\nPt with Pathologic fx left humerus, ORIF yesterday. Low BP and U/O, distended Abdomen, small ileus.\n\nCVS: Afebrile. HR=87-102 NSR no ectopy noted. SBP=100-115. CVP=. IV NS at 150cc/h but Receiving multiple IV NS boluses for low u/o.\n\nLabs: MG=1.6 Given 2GM MGSO4 IV, K=2.8 given 20meq KCL bolus IV x2, Ionized CA++=1.07 given 2amps CAgluconate IV.\n\nResp: O2 at 3l nc, ABG's improved. Lung sounds clear. Sats=95-98%. Coughs and deep breathes well. Coughed up small amt clear sputum.\n\nGI: NGT to LWS drained 1375cc green bilious since mn. Bowel sounds present. Pt had two small loose brown stools.\n\nGU: U/O=10-26cc/h. Fluid boluses as noted above.\n\nSkin: Left arm incision=clean,dry and intact. Reddened rt groin.\n\nPain: PCA MSO4 providing good pain control. Pain is mostly in abdomen when turning side to side due to Small ileus noted on CT scan. However, pt says pain much better this am.\n\nNeuro: A&Ox3, No deficits noted. MAE.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-09 00:00:00.000", "description": "Report", "row_id": 1337461, "text": "CONDITION UPDATE\nASSESSMENT:\n PT ~ 7AM FROM FLOOR. PT ORIENTED AND APPROPRIATE. OCCASIONALLY COMPLAINING OF PAIN FROM RIGHT ARM INCISION. MORPHINE PCA STARTED WITH ADEQUATE RELIEF. HEART RATE 80'-90'S NORMAL SINUS. CUFF BP SLIGHTLY LOW THIS MORNING AFTER LASIX DOSE AND PAIN MED, NOW WITH SYSTOLIC > 100. PT RESPONDED TO LASIX BUT URINE OUTPUT NOW TAPERING OFF.\n LUNG SOUNDS CLEAR & SP02 97% WITH NASAL CANNULA. A-LINE PLACED BY DR. , PA02 76 BUT PT IN NO RESP DISTRESS. ABDOMEN OBESE AND DISTENDED, POSITIVE BOWEL SOUNDS IN AFTERNOON. ABDOMINAL CT SCAN DONE FOR ? OBSTRUCTION, AWAITING RESULTS. NPO AND NGT CURRENTLY DRAINING READI-CAT.\nPLAN:\n AWAIT RESULTS OF CT SCAN. PHYSICAL THERAPY/OCCUPATIONAL THERAPY. PULMONARY HYGIENE.\n" }, { "category": "Radiology", "chartdate": "2111-02-03 00:00:00.000", "description": "INT.SHTH NOT/GUID,EP,NONLASER", "row_id": 858238, "text": " 7:20 AM\n OTHER EMBO Clip # \n Reason: Please embolize metastastic lesion left distal humerus on 3/\n ********************************* CPT Codes ********************************\n * INTRO CFA/SFA/ILIAC/ GRAFT C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with metastatic renal cell ca\n REASON FOR THIS EXAMINATION:\n Please embolize metastastic lesion left distal humerus on in preparation\n for ORIF on \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a 67-year-old woman with renal cell carcinoma and a\n pathologic fracture in her distal left humerus secondary to a lytic lesion.\n\n RADIOLOGISTS: The procedure was performed by Drs. and \n . Dr. , the attending radiologist, was present and supervising\n throughout the procedure.\n\n CONSENT: After receiving an explanation of the benefits and risks of the\n procedure, written informed consent was obtained from the patient.\n\n TECHNIQUE: The patient was placed supine on the angiography table. Both sides\n of the groin were prepared in a sterile fashion. Since no palpable pulse could\n be felt, ultrasound was used to localized the right common femoral artery.\n Using the Seldinger technique a 19 gauge needle was advanced under\n fluoroscopic guidance into the right common femoral artery, after local\n anestehesia with 5cc of Lidocaine 1%. A 0.035 guide wire was advanced\n through the needle into the abdominal aorta. The needle was removed over the\n wire, and a 4 Fr sheath was then advanced over the wire into the artery. Since\n there was some resistance to advance the sheath, contrast was injected. This\n stagnant flow consistent with passing through a stenosed area and having the\n sheath occluding the right common femoral artery. Therefore, the sheath was\n removed and pressure was held until hemostasis was achieved. Then attention\n was given to the left groin. No palpable pulse could be felt. The patient was\n extremely uncomfortable lying on the table complaining of chest pain and\n dyspnea. Therefore, decision was made to abort this procedure. This was\n informed to the patient's attending orthopedic surgeon.\n\n COMPLICATIONS: There were no immediate complications.\n\n" }, { "category": "Radiology", "chartdate": "2111-02-09 00:00:00.000", "description": "CT 150CC NONIONIC CONTRAST", "row_id": 858972, "text": " 11:02 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please assess for bowel obstruction. Please use oral and IV\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with worsening abd pain and low uop, decreasing flatus\n\n REASON FOR THIS EXAMINATION:\n Please assess for bowel obstruction. Please use oral and IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 68-year-old woman with worsening abdominal pain and low urine\n output with decreasing flatus. Status post ORIF of the left humerus on\n . Also, history of renal cell carcinoma with brain and renal\n metastases.\n\n COMPARISONS: CT torso of .\n\n TECHNIQUE: Axial images of the abdomen and pelvis were acquired with oral and\n IV contrast.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a new pleural-based mass at the\n right base measuring 2.0 x 3.9 cm. Adjacent atelectatic changes and a tiny\n right-sided pleural effusion are also present. Otherwise, the appearance of\n multiple pulmonary nodules noted at the left base is similar. The large\n cystic lesion in the liver has an unchanged appearance. Surgical clips are\n seen in the gallbladder fossa consistent with prior cholecystectomy. The\n pancreas and spleen are unremarkable. The right kidney is unremarkable. There\n is a new right adrenal mass measuring 10 x 25 mm. The size of the previously\n described lesion in the left nephrectomy bed, however, is somewhat smaller and\n measures 3.5 x 4.4 cm in axial dimensions.\n\n There are new mesenteric masses in the upper abdomen. One measures 17 x 36 mm\n and the second one 12 mm in diameter. There is no retroperitoneal\n lymphadenopathy or free air. A small amount of perihepatic ascites is noted,\n however. Edema seen extensively in the subcutaneous soft tissues.\n\n A nasogastric tube lies in suitable position with its tip in the distal\n stomach. Contrast passes into the proximal jejunum only. More distally, the\n small bowel is mostly filled with fluid. There is fecal material and gas in\n the colon. There are areas of mild small bowel dilatation, and segments of\n mild colonic dilatation as well, most notably in the transverse colon.\n However, no transition point is seen, and the overall pattern is consistent\n with adynamic ileus.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in the urinary\n bladder. There is no pelvic lymphadenopathy or free fluid. Subcutaneous\n edema is noted. Fluid and fecal material are seen in the rectum and sigmoid.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n (Over)\n\n 11:02 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please assess for bowel obstruction. Please use oral and IV\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1) Likely adynamic ileus with no evidence of small or large bowel\n obstruction.\n\n 2) More extensive metastatic disease as described.\n\n\n" }, { "category": "ECG", "chartdate": "2111-02-02 00:00:00.000", "description": "Report", "row_id": 187447, "text": "Sinus rhythm\nRight bundle branch block\nSince previous tracing of , no significant change\n\n" } ]

[ { "category": "Echo", "chartdate": "2124-10-25 00:00:00.000", "description": "Report", "row_id": 88485, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Cardiomyopathy. Mitral valve disease.\nHeight: (in) 68\nWeight (lb): 184\nBSA (m2): 1.97 m2\nBP (mm Hg): 84/55\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 16:43\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Severely depressed\nLVEF. Cannot exclude LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nakinetic; mid inferior - akinetic; basal inferolateral - hypo; mid\ninferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo;\nanterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex -\nhypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Overall left ventricular systolic\nfunction is severely depressed (LVEF= 25 %). There is global hypokinesis with\nakinesis of the inferior wall. A left ventricular mass/thrombus cannot be\nexcluded. Right ventricular chamber size and free wall motion are normal. The\naortic root is mildly dilated at the sinus level. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nIMPRESSION: Regional and global left ventricular systolic dysfunction. Normal\nright ventricular systolic function. No pathologic valvular abnormalities\nidentified.\n\nCompared with the prior study (images reviewed) of , overall ejection\nfraction has improved and left ventricular cavity size is smaller. Right\nventricular function has improved. The heart rate is slower.\n\n\n" }, { "category": "Echo", "chartdate": "2124-10-17 00:00:00.000", "description": "Report", "row_id": 88486, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function\nHeight: (in) 71\nWeight (lb): 190\nBSA (m2): 2.07 m2\nBP (mm Hg): 104/64\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nSeverely depressed LVEF. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - akinetic; mid inferolateral -\nakinetic; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex\n- hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. RV function\ndepressed.\n\nAORTA: Normal aortic diameter at the sinus level. Normal aortic arch diameter.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. Trace AR.\n\nMITRAL VALVE: LV inflow pattern c/w restrictive filling abnormality, with\nelevated LA pressure.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Suboptimal image quality - poor echo windows.\nSuboptimal image quality as the patient was difficult to position. Suboptimal\nimage quality - body habitus. Suboptimal image quality - ventilator.\nSuboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated. Overall left\nventricular systolic function is severely depressed (LVEF = 15 %) secondary to\nakinesis of the entire posterior wall, and hypokinesis (with regional\nvariation) of the rest of the left ventricle - basal segments relatively\nwell-preserved. No masses or thrombi are seen in the left ventricle. The right\nventricular free wall is hypertrophied. Right ventricular chamber size is\nnormal. with depressed free wall contractility. The aortic valve is not well\nseen. There is no aortic valve stenosis. Trace aortic regurgitation is seen.\nThe left ventricular inflow pattern suggests a restrictive filling\nabnormality, with elevated left atrial pressure. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2124-10-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1255988, "text": " 8:45 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for lead position, hemo/pneumothorax\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with new ICD\n REASON FOR THIS EXAMINATION:\n eval for lead position, hemo/pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for lead position, rule out pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. In the interval, the\n patient has received a pacemaker, the generator is in left pectoral position,\n the course of the leads is unremarkable, the tip of the lead projects over the\n right ventricle. There is no evidence of complications such as pneumothorax.\n No evidence of pulmonary edema. No pleural effusions.\n\n\n" }, { "category": "ECG", "chartdate": "2124-10-20 00:00:00.000", "description": "Report", "row_id": 235471, "text": "Normal sinus rhythm with left bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterval change.\n\n\n" }, { "category": "ECG", "chartdate": "2124-10-19 00:00:00.000", "description": "Report", "row_id": 235472, "text": "Sinus rhythm. Left bundle-branch block. Frequent ventricular premature\ncontractions. Compared to the previous tracing ventricular ectopy is new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2124-10-18 00:00:00.000", "description": "Report", "row_id": 235473, "text": "Sinus tachycardia. Left bundle-branch block. Compared to the previous tracing\nno change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2124-10-17 00:00:00.000", "description": "Report", "row_id": 235474, "text": "Sinus tachycardia. Borderline Q-T interval prolongation. Left bundle-branch\nblock. ST segment changes in the inferolateral leads. No previous tracing\navailable for comparison.\n\n" }, { "category": "ECG", "chartdate": "2124-10-25 00:00:00.000", "description": "Report", "row_id": 235470, "text": "Sinus rhythm. Premature ventricular complexes. Possible left ventricular\nhypertrophy with repolarization abnormalities. Compared to the previous\ntracing of the left bundle-branch block has resolved, repolarization\nabnormalities are similar, and ventricular ectopy is new.\n\n" }, { "category": "Radiology", "chartdate": "2124-10-20 00:00:00.000", "description": "MR CARDIAC MORPH/FX P/P CONTRAST", "row_id": 1255627, "text": " 12:29 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: evaluate anatomy pre-VT ablation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: MULTIHANCE Amt: 15CC .1 MH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with CAD s/p PCIX2 to the LCx (,), systolic CHF (EF=40%\n in ) and T2DM, COPD on home O2 p/w ventricular tachycardia\n REASON FOR THIS EXAMINATION:\n evaluate anatomy pre-VT ablation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n Patient Name: Date of Study: \n Date of Birth: Requesting Physician: , MD\n Age (years): 51 CMR Staff: , MD\n Gender: Male Radiology Staff: , MD\n Technologist: Goddu, RT\n Status: Inpatient Nursing Support: , RN\n\n Height (in): 70 Injection Site: left hand vein\n Weight (lbs): 202 Contrast Type: Gd-BOPTA (Multihance)\n Body Surface Area (m ): 2.13 Contrast Dose (mmol/kg): 0.1\n Blood Pressure (mmHg): 111/55 Contrast Amount (ml): 15\n Heart Rate(bpm): 98 Creatinine (mg/dl): 0.8\n Rhythm: Sinus rhythm Creatinine Date: \n Complications: None. eGFR (ml/min1.73mm ): 124\n\n\n Indication: Coronary artery disease. Pre-VT ablation\n\n CMR MEASUREMENTS:\n\n Measurement Result Normal Range\n Left Ventricle\n LV End-Diastolic Dimension (mm) **71 <62\n LV End-Diastolic Dimension Index (mm/m ) *33 <32\n LV End-Systolic Dimension (mm) 62\n LV End-Diastolic Volume (ml) **267 <196\n LV End-Diastolic Volume Index (ml/m ) **125 <95\n LV End-Systolic Volume (ml) 214\n LV Stroke Volume (ml) 53\n LV Stroke Volume Index (ml/m ) 25\n LV Ejection Fraction (%) ***20 >=54\n LV Regional Wall Motion Globally hypokinetic\n LV Mass (g) 160\n LV Mass Index (g/m ) 75 <80\n Basal antero-septal wall thickness (mm) 9 <12\n Basal infero-lateral wall thickness (mm) 7 <11\n Basal anterior wall motion Akinetic\n Basal antero-lateral wall motion Akinetic\n (Over)\n\n 12:29 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: evaluate anatomy pre-VT ablation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: MULTIHANCE Amt: 15CC .1 MH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Mid antero-lateral wall motion Akinetic\n Basal anterior late gadolinium enhancement 76-100% (ischemic type)\n Basal antero-lateral late gadolinium\n enhancement 76-100% (ischemic type)\n Mid antero-lateral late gadolinium\n enhancement 76-100% (ischemic type)\n Q-Flow Aortic Net Forward Stroke Volume (ml) 52\n Q-Flow Aortic Total Stroke Volume (ml) 53\n Q-Flow Aortic Cardiac Output (l/min) 5.1\n Q-Flow Aortic Cardiac Index (l/min/m ) 2.4\n LV Effective Forward Ejection Fraction (%) ***19 >=54\n Right Ventricle\n RV End-Diastolic Volume (ml) 97\n RV End-Diastolic Volume Index (ml/m ) 46 58-114\n RV End-Systolic Volume (ml) 42\n RV Stroke Volume (ml) 55\n RV Stroke Volume Index (ml/m ) 26\n RV Ejection Fraction (%) 57 >=46\n Q-Flow Pulmonary Net Forward Stroke Volume (ml) 55\n Q-Flow Pulmonary Total Stroke Volume (ml) 55\n Qp/Qs 1.06 0.8-1.2\n Atria\n Left Atrial Dimension (Axial) (mm) 34 <40\n Left Atrial Length (4-Chamber) (mm) 49 <52\n Right Atrial Dimension (4-Chamber) (mm) 36 <50\n Coronary Sinus Diameter (mm) 6 <15\n Great Vessels\n Ascending Aorta Diameter (mm) 32 <39\n Ascending Aorta Diameter Index (mm/m ) 15 <20\n Transverse Aorta Diameter (mm) 26\n Transverse Aorta Diameter Index (mm/m ) 12\n Descending Aorta Diameter (mm) 21 <28\n Descending Aorta Index (mm/m ) 10 <14\n Abdominal Aorta Diameter (mm) 21\n Abdominal Aorta Diameter Index (mm/m ) 10\n Main Pulmonary Artery Diameter (mm) 27 <29\n Main Pulmonary Artery Diameter Index (mm/m ) 13 <15\n Valves\n Aortic Valve Morphology Trileaflet\n Aortic Valve Excursion Normal\n Aortic Valve Area (cm ) 4.1 >=2\n Aortic Valve Area Index (cm /m ) 1.9\n Aortic Valve Regurgitation (Visual) None present\n Aortic Valve Regurgitant Volume (ml) 1\n Aortic Valve Regurgitant Fraction (%) 2 <5\n (Over)\n\n 12:29 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: evaluate anatomy pre-VT ablation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: MULTIHANCE Amt: 15CC .1 MH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Mitral Valve Regurgitation (Visual) None present\n Mitral Valve Regurgitant Volume (ml) 0\n Mitral Valve Regurgitant Fraction (%) 0 <5\n Pulmonary Valve Regurgitation (Visual) None present\n Pulmonary Valve Regurgitant Volume (ml) 0\n Pulmonary Valve Regurgitant Fraction (%) 0 <5\n Tricuspid Valve Regurgitation (Visual) None present\n Tricuspid Valve Regurgitant Volume (ml) 0\n Tricuspid Valve Regurgitant Fraction (%) 0 <5\n Pericardium\n Pericardial Thickness (mm) 2 <4\n\n * Mildly abnormal | ** Moderately abnormal | *** Severely abnormal\n\n CMR TECHNICAL INFORMATION:\n Structure\n \" T1-Weighted (Black Blood): Dual-inversion T1-weighted fast spin echo images\n were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular\n anatomy.\n\n Function\n \" Cine SSFP: Breath-hold SSFP cine images were acquired in 8-mm slices in the\n 4-chamber, 3-chamber, 2-chamber, and short axis orientations.\n \" Cine SSFP (Additional Right Heart Views): Additional breath-hold SSFP cine\n images were acquired to further evaluate the right heart, pulmonary valve, and\n pulmonary arteries.\n\n Flow\n \" Aortic Valve Flow: Phase-contrast cine images were acquired transverse to\n the proximal ascending aorta to quantify through-plane flow.\n \" Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse\n to the main pulmonary artery to quantify through-plane flow.\n\n Viability\n \" LGE: Late gadolinium enhancement (LGE) images were acquired using an\n ultrafast gradient echo inversion-recovery sequence with spectral fat\n saturation pre-pulses 15 minutes after injection of a total of 0.1 mmol/kg (15\n mL) Gd-BOPTA (Multihance).\n \" LGE (3D PSIR): Late gadolinium enhancement (LGE) images were acquired using\n a navigator-gated 3D phase sensitive inversion-recovery (PSIR) sequence with\n spectral fat saturation pre-pulses 15 minutes after injection of a total of\n 0.1 mmol/kg (15 mL) Gd-BOPTA (Multihance).\n\n CMR FINDINGS:\n Left Ventricle\n (Over)\n\n 12:29 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: evaluate anatomy pre-VT ablation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: MULTIHANCE Amt: 15CC .1 MH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n \" LV cavity size: Moderately increased\n \" LV ejection fraction: Severely depressed\n \" LV regional wall motion: Globally hypokinetic\n \" LV mass: Normal\n \" Basal anterior wall motion: Akinetic\n \" Basal antero-lateral wall motion: Akinetic\n \" Mid antero-lateral wall motion: Akinetic\n \" Basal anterior late gadolinium enhancement: 76-100% (ischemic type)\n \" Basal antero-lateral late gadolinium enhancement: 76-100% (ischemic type)\n \" Mid antero-lateral late gadolinium enhancement: 76-100% (ischemic type)\n\n Right Ventricle\n \" RV cavity size: Small\n \" RV ejection fraction: Normal\n \" Intra-cardiac shunt: None present\n\n Atria\n \" LA size: Normal\n \" RA size: Normal\n\n Great Vessels\n \" Ascending aortic diameter: Normal\n \" Main pulmonary artery diameter: Normal\n\n Valves\n \" Aortic valve morphology: Trileaflet\n \" Aortic stenosis: No\n \" Aortic regurgitation jet: None present\n \" Mitral regurgitation jet: None present\n \" Pulmonary regurgitation jet: None present\n \" Tricuspid regurgitation jet: None present\n\n Pericardium\n \" Pericardial thickness: Normal\n\n ADDITIONAL INFORMATION/FINDINGS:\n None\n\n NON-CARDIAC FINDINGS:\n Bilateral lung dependent atelectasis with small bilateral pleural effusions.\n\n IMPRESSION:\n Mildly enlarged left atrium and normal size right atrium. Increased left\n ventricular cavity. Thinned and akinetic antero-basal and mid-basal antero-\n lateral walls. Moderately hypokinesis of the other ventricular segments with\n (Over)\n\n 12:29 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: evaluate anatomy pre-VT ablation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: MULTIHANCE Amt: 15CC .1 MH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n probable dyssynchrony also present. Transmural late gadolinium enhancement of\n the antero-basal and mid-basal antero-lateral wall, consistent with fibrosis\n or scar, and low likelihood of contractile recovery after revascularization.\n No evidence of late gadolinium enhancement in the other, hypokinetic, left\n ventricular segments. Normal right ventricular cavity size and function. The\n ascending aorta, descending aorta and main pulmonary artery were normal. No\n significant aortic or mitral regurgitation. No pericardial effusion.\n\n Interpreted by Drs.: Murilo , , , , and\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2124-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1255299, "text": " 6:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 51M with intubated transfer\n REASON FOR THIS EXAMINATION:\n ett position\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male recently intubated. Evaluate for position of\n endotracheal tube.\n\n COMPARISON: None available.\n\n TECHNIQUE: Portable supine chest radiograph.\n\n FINDINGS: There are bilateral diffuse airspace opacities, with more confluent\n consolidations in the lung bases. A nodular component cannot be excluded.\n Assessment of the pleural sulci is limited as both were left out of the\n imaging frame. The cardiomediastinal and hilar contours are unremarkable.\n There is no pneumothorax.\n\n Endotracheal tube is seen ending 4.8 cm above the carina. There is no\n cardiomegaly.\n\n IMPRESSION:\n 1. Severe diffuse bilateral airspace opacities might represent pulmonary\n edema, pulmonary hemorrhage or widespread infection. Further assessment with\n chest CT is recommended.\n 2. Endotracheal tube ending 4.8 cm above the carina.\n\n" }, { "category": "Radiology", "chartdate": "2124-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1255407, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question interval change, assess for underlying PNA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with CAD, CHF, DM, and COPD p/w ventricular tachycardia.\n REASON FOR THIS EXAMINATION:\n question interval change, assess for underlying PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable AP chest radiograph.\n\n COMPARISON EXAM: Portable AP chest radiograph .\n\n INDICATION: 51-year-old with multiple comorbidities presenting with\n ventricular tachycardia. Assess interval change.\n\n FINDINGS: ET tube remains in good position. There is an upper alimentary\n tube whose tip is not seen, but appears to be coiled towards its distal end.\n Bilateral diffuse airspace opacities are much improved on this study, but\n slight increased markings in the bilateral upper lobes and the right lower\n lobe are still present. There is no pleural effusion or pneumothorax.\n Cardiomediastinal and hilar contours are normal.\n\n IMPRESSION: Almost complete resolution of bilateral diffuse airspace\n opacifications consistent with diagnosis of pulmonary edema.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2155-04-27 00:00:00.000", "description": "Report", "row_id": 1540459, "text": "T/SICU NURSING ADMISSION NOTE 5AM-7A\n PT IS AN 83YO WHO WENT TO EW WITH ONE DAY HX OF SEVERE DIFFUSE ABDOMINAL PAIN THAT RADIATED TO EPIGASTRIC AREA, BACK, AND R SHOULDER. PT N/V SO SHE WENT OSH WHERE CT REVEALED GALL BLADDER PANCREATITIS. TRANSFER TO FOR FURTHER W/U. ADMITTED TO ICU FOR HEMODYNAMIC MONITORING.\n\nALL: NKDA\nHX: HTN, HIGH CHOL, CAD WITH CABG, AND NIDDM\nMEDS: ATENOLOL, GLYBURIDE, ASA, LIPITOR, KLONAPIN, AND MECLIZINE.\n\nREVIEW OF SYSTEMS\n\nNEURO: AOX3 AND PLEASANT. FOLLOWING COMMANDS CONSISTANTLY. C/O MILD PAIN IN ABD. DENYING NEED FOR PAIN MED.\n\nCV: HR 70'S SR WITH PACS. SBP 110'S. NO CARDIAC COMPLAINTS. PIV X2.\n\nRESP: L/S CLEAR. 024L WITH SATS 98%. NO SOB OR RESP DISTRESS NOTED.\n\nGI: ABD SOFT WITH HYPOACTIVE BS. REMAINS NPO. NO STOOL OR FLATUS.\n\nGU: U/O ADEQUATE. IVF LR AT 200CC/HR.\n\nHEME: STABLE.\n\nENDO: SS ORDERED.\n\nID: NO ANTIBIOTICS ORDERED.\n\nSKIN; INTACT.\n\nSOCIAL: PT LIVES ALONE. FRIEND BROUGHT HER TO EW AND HER FRIEND WILL CALL HER BROTHER THIS AM.\n\nPLAN: CONT HEMODYNAMIC MONITORING, PLACE CENTRAL LINE, AND CONT FLUID RESUSCITATION.\n" }, { "category": "Nursing/other", "chartdate": "2155-04-27 00:00:00.000", "description": "Report", "row_id": 1540460, "text": "T/SICU NPN-\nBrief ROS:\nNeuro- Intact. Cooperative and appropriate all shift. Anxious about \"needles\". \"Can i be knocked out while they put that IV in my neck?\". Pt. experiencing intermittant pain with some nausea, mild. She had morphine 1mg this am for abd pain. C/O pain in her back r/t being in bed and stiff.\n\nCV- Stable BP and HR. Rhythm is irregular, many apc's, pauses. Skin warm and dry, palpable periph pulses. Minimal periph edema. Plan for central line changed, will manage pt. with periph per Dr. . LR @ 200/hr.\n\nResp- Clear BS, gd sats with 3l NC.\n\nGI- NPO. \"I'm hungry\" Hypoactive BS. Swabing mouth freq.\n\nGU- Adequate u/o via foley.\n\nHeme- Labs pnd. SQ heparin. Pneumo boots. ID- No further abx ordered. Afeb.\n\n Pt.'s , called. Friend(brought her to the hosp yesterday) visited today.\n\nA: Stable shift. IVF 200cc/hr. Adequate uo. Improved pain status. Awaiting MRCP.\n\nP: Monitor vs. Cont. hydration. MRI when possible. Explain all activity to pt. to alleviate anxiety. Pain med as needed.\n" }, { "category": "Nursing/other", "chartdate": "2155-04-28 00:00:00.000", "description": "Report", "row_id": 1540461, "text": "ROS:\n\nNeuro: Alert oriented x's 3. MAE x's 4. PEARRLA. Denies numbness tingling in extremities.\n\nCV: SB-RSR w/ frequent PACs. VSS. Peripheral pulses palpable w/ease. DVT prophylaxis w/sub q heparin and SCDs bilaterally. No edema.\n\nResp: Lungsound clear. Sao2 97%. = rise and fall of chest, no resp distress noted. O2 remains on at 3L/np\n\nGI: Abd soft and round w/hypo active BS. NPO. Uses moist swabs for po cares.\n\nGU. Foley patent draininng clearr yellow urine in amt sufficiant.\n\nEndo: no RSSI required\n\nLabs: stable.\n" }, { "category": "Radiology", "chartdate": "2155-04-27 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 826809, "text": " 4:04 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ruq pain with elevated lipase eval for cbd stone.\n Admitting Diagnosis: GALLSTONES-PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with\n REASON FOR THIS EXAMINATION:\n ruq pain with elevated lipase eval for cbd stone.\n ______________________________________________________________________________\n WET READ: DFDkq SUN 4:40 AM\n cholelithiasis without evidence of acute cholecystitis; CBD dilated but can't\n be followed throughout due to pt's body habitus and inability to hold her\n breath; suggest MRCP\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Right upper quadrant abdominal pain and elevated lipase.\n\n COMPARISON: CT scan of the abdomen and pelvis performed at \n Hospital on under medical record number G00013381 and clip number\n G000028801.\n\n FINDINGS: There is a large stone in the gallbladder neck, which is not\n demonstrated to change its position during the exam. The gallbladder is\n distended. There is no gallbladder wall edema or pericholecystic fluid. No\n son sign was elicited. However, the patient was receiving\n pain medication.\n\n The common bile duct is dilated, measuring 10 mm. This is above the expected\n size for the patient's age. There is no intrahepatic biliary dilatation.\n However, the common bile duct could not be evaluated throughout its course\n secondary to the patient's body habitus and inability to hold her breath. No\n common bile duct stones were identified on limited evaluation. MRCP may be\n helpful for further investigation.\n\n The findings were discussed with Dr. at 5 AM on .\n\n IMPRESSION: 1. Large stone in the gallbladder neck without signs of acute\n cholecystitis. Serial exams and follow-up are recommended.\n\n 2. Dilated common bile duct. No common bile duct stones identified on limited\n evaluation. MRCP would be helpful for further investigation.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-30 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 827191, "text": " 3:53 PM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: eval for pancreatic necrosis.\n Admitting Diagnosis: GALLSTONES-PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with gallstone pancreatitis-no improvement.\n REASON FOR THIS EXAMINATION:\n eval for pancreatic necrosis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gallstone, pancreatitis without improvement; please evaluate for\n pnacreatic necrosis.\n\n TECHNIQUE: Axial pre and post contrast CT of the abdomen and pelvis\n with multiplanar reformats using the pancreatic CTA protocol.\n\n FINDINGS:\n\n PRE/POST CONTRAST CT ABDOMEN: There are small bilateral pleural effusions at\n the lung bases with adjacent compressive atelectasis.\n\n The liver enhances in a normal fashion. No focal mass. The gallbladder\n contains fluid and at least one gallstone which is located down near the\n gallbladder neck. This gallstone measures 1.5 cm in greatest diameter.\n\n There is mild peripancreatic stranding adjacent to the pancreas along its\n entire extent. The pancreas, however, enhances in a normal fashion and is\n without evidence of necrosis. There is no focal peripancreatic fluid\n collection. There is, however, evidence of a pancreas divisum however the\n pancreatic duct is not overly dilated. The common bile duct measures up to 10\n mm in diameter which is only mildly dilated for a patient of this age.\n\n The spleen, adrenals and right kidney enhance in a normal fashion. No\n hydronephrosis on the right. On the left, there are two rounded low density\n areas, one is located in the upper pole of the kidney measuring 0.7 x 0.7 cm.\n There is also a rounded interpolar region measuring 0.8 x 0.7 cm. These are\n too small to further characterize by CT. There is no hydronephrosis on\n the left.\n\n There is no abdominal ascites or pneumperitoneum. No abnormally thickened or\n dilated abdominal bowel loops. No pathologic abdominal lymphadenopathy.\n\n PRE AND POST CONTRAST CT PELVIS: No abnormally thickened or dilated pelvic\n bowel loops. No pathologic pelvic lymphadenopathy or ascites.\n\n Multiple calcifications are seen in a multilobulated appearing uterus. This\n is likely to represent multiple calcified fibroids. If there is concern for a\n pelvic process a pelvic ultrasound can be considered.\n\n There is no pelvic ascites.\n (Over)\n\n 3:53 PM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: eval for pancreatic necrosis.\n Admitting Diagnosis: GALLSTONES-PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n No lytic or blastic destructive osseous lesions.\n\n MULTIPLANAR REFORMATS: The multiplanar reformats clearly demonstrate the\n presence of a pancreas divisum. There is very mild narrowing of the origin of\n the superior mesenteric artery but the splenic arteries are otherwise patent.\n There is atherosclerotic calcification of the splenic artery. The inferior\n mesenteric artery is patent.\n\n IMPRESSION:\n\n 1) No evidence of pancreatic necrosis as clinically questioned.\n 2) Mild peripancreatic stranding consistent with a history of pancreatitis.\n 3) Findings of pancreas divisum.\n 4) Gallstone.\n 5) Multilobulated and calcified uterus is likely to represent calcified\n fibroids; if there is concern for pelvic process and pelvic ultrasound can be\n considered.\n 6) Two sub-cm hypodensities within the left kidney are too small to fully\n characterize by CT.\n\n\n" } ]

[ { "category": "Nutrition", "chartdate": "2164-02-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 370067, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 78.8 kg\n 24.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 77 kg\n 102%\n Diagnosis: pna\n PMH :\n Food allergies and intolerances: milk\n Pertinent medications: heparin, D5 1/2 NS @ 75 ml/hr, RISS,IV abx,\n protonix, methylprednisone, others noted\n Labs:\n Value\n Date\n Glucose\n 181 mg/dL\n 05:43 AM\n Glucose Finger Stick\n 224\n 06:00 AM\n BUN\n 21 mg/dL\n 05:43 AM\n Creatinine\n 1.1 mg/dL\n 05:43 AM\n Sodium\n 140 mEq/L\n 05:43 AM\n Potassium\n 3.5 mEq/L\n 05:43 AM\n Chloride\n 98 mEq/L\n 05:43 AM\n TCO2\n 31 mEq/L\n 05:43 AM\n pH (urine)\n 5.0 units\n 04:21 PM\n Albumin\n 2.6 g/dL\n 05:09 AM\n Calcium non-ionized\n 8.8 mg/dL\n 05:43 AM\n Phosphorus\n 4.6 mg/dL\n 05:43 AM\n Magnesium\n 2.4 mg/dL\n 05:43 AM\n ALT\n 27 IU/L\n 05:09 AM\n Alkaline Phosphate\n 157 IU/L\n 05:09 AM\n AST\n 39 IU/L\n 05:09 AM\n Total Bilirubin\n 0.3 mg/dL\n 05:09 AM\n WBC\n 16.5 K/uL\n 05:43 AM\n Hgb\n 10.2 g/dL\n 05:43 AM\n Hematocrit\n 33.3 %\n 05:43 AM\n Current diet order / nutrition support: soft, thin liquids\n PPN Order: 1.5 L 75 g dextrose/ 52.5 g Amino Acids/ lipids 20% in 250\n ml\n GI: soft, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake, NPO / hypocaloric diet, multiple\n pressure ulcers\n Estimated Nutritional Needs\n Calories: -2310 (BEE x or / 25-30 cal/kg)\n Protein: 92-116 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n At risk for refeeding syndrome (monitor K / PO4 / Magnesium and repeat\n as needed):\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Change to non-dextrose IV fluids\n Comments:\n" }, { "category": "Echo", "chartdate": "2164-02-15 00:00:00.000", "description": "Report", "row_id": 70796, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 70\nWeight (lb): 170\nBSA (m2): 1.95 m2\nBP (mm Hg): 116/67\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 11:13\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Prominent Eustachian valve\n(normal variant).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Transmitral\nand tissue Doppler imaging suggests normal diastolic function, and a normal\nleft ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Normal regional and global biventricular systolic function. Mild\nmitral regurgitation. There appears to be a mass that is external to the\nlateral and posterior sides of the right atrium. This mass is\nindenting/compressing the right atrium without causing hemodynamic compromise.\nThis is probably the same mass/lymhpadenopathy seen on the recent chest CT.\n\n\n" }, { "category": "Nursing", "chartdate": "2164-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369756, "text": "Hypoxemia\n Assessment:\n Pt on humidified aerosol mask 50%, lungs CTA upper lobes, diminished at\n bases with periods of desat, ? related to anxiety\n Action:\n Pt placed on non-rebreather, 0.12 mg xanax given\n Response:\n O2 sats > 98% on non-rebreather\n Plan:\n Continue to monitor respiratory status, monitor VS\n .H/O anxiety\n Assessment:\n pt calling out\ngive me xanax, give me xanax. You \n me to get\n upset\n. O2 sats mid 80s on humidified aerosol mask\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369933, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, started on\n halodol 2 mg IV as PRN basis. Geriatric consulted. Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LS rhonchorous bilaterally,\n diminished at bases; continues on vacno/zosyn/levaquin, no sputum\n culture as pt unable to produce. Patient refused neb treatments.\n Action:\n Nebs q6h as tolerates, remains on NRB, attempted to wean off, but\n patient becomes agitated and desats to 80\ns. Vanc level yesterday am\n was 21. Pt. dosed this evening with 750mg instead of 1gm. Will check\n trough in am prior to dosing.\n Response:\n Sating high 90\ns on NRB, RR 20-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings on right changed\n overnight, applied. Sacral changed overnight.\n Response:\n No changes\n Plan:\n Plastics and wound care following. Change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given. Also,\n given additional 0.5mg Ativan 1 time dose. Haldol 2 mg IV X1 given.\n Response:\n Pt very agitated, yelling out, denies pain, continues to refuse PO\n meds, MD aware. RR at 16-20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 74 at MN.\n Response:\n Heparin gtt therapeutic remains @ 1500 units /hr .\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 6am pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete.\n Action:\n Second liter D5\n NS at 75 cc/hr started . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds. K 5.4 at MN, IVF changed to D51/2NS\n at 75cc/hr.\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Physician ", "chartdate": "2164-02-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 369726, "text": "Chief Complaint: Dyspnea\n HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Infusions:\n Heparin Sodium - 2,000 units/hour\n Other medications:\n Heparin drip\n Vancomycin\n Levofloxacin\n Zosyn\n Clonazepam\n Colace\n Duragesic\n Baclofen\n Omeprazole\n Singulair\n Mexilitine\n Methadone\n Theophyllline\n Past medical history:\n Family history:\n Social History:\n Sampters Syndrome: asa sensitivity, nasal polyps, asthma\n Transverse myelitis - since 's related to viral infection\n Anxiety\n Chronic Pain\n Asthma\n Non-contributory\n Occupation: Former physicist - worked in optics\n Drugs:\n Tobacco: Remote history of smoking\n Review of systems:\n As per resident admission note\n Flowsheet Data as of 04:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 108 (108 - 108) bpm\n BP: 135/66(82) {135/66(82) - 135/66(82)} mmHg\n RR: 18 (18 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 152 mL\n PO:\n TF:\n IVF:\n 152 mL\n Blood products:\n Total out:\n 0 mL\n 890 mL\n Urine:\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -738 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 633 K/uL\n 28.5 %\n 9.6 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 5 mg/dL\n 34 mEq/L\n 92 mEq/L\n 3.4 mEq/L\n 132 mEq/L\n 13.6 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 13.6\n Hct\n 28.5\n Plt\n 633\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 104\n Other labs: PT / PTT / INR:14.6/28.2/1.3, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 62M with h/o transverse myelitis, sampter's triad, asthma; admitted\n with clinical course that is a fairly rapid deterioration in his\n respiratory status, waxing and degress of severe hypoxemia, and\n evidence of severe bilateral ground glass opacities superimposed on\n possible ILD with peripheral fibrosis. At this point, the differential\n includes possible recurrent aspiration events and chemical pneumonits.\n The cllinical course seems too rapid for ILD; though it is possible he\n had subclinical progression given some evidence of underlying fibrosis\n (? UIP/NSIP, possible related to recurrent aspiration); and this is an\n exacerbation of a previously unrecognized chronic process such as UIP.\n As for infectious etiologies, he has been covered with\n vancomycin/zosyn/levofloxacin, and we have been unable to obtain sputum\n samples. He is not at particular risk of opportunistic infections as\n he has not been prescribed prednisone and does not have any known\n malignancy. Eosinophilic disease is possible, but also seems unlikely.\n He is in a difficult situation at the present time. His degree of\n hypoxemia precludes bronchoscopy without prompting intubation, and\n would not desire to intubate for bronch given predicted difficulty in\n extubation were that to occur. Ideally, will await some degree of\n improvement of his oxygenation, then perhaps can undertake bronchoscopy\n safely. Alternatively, if he gets worse and requires intubation and\n mechanical ventilation; could potentially bronch and BAL at that time.\n Am also reluctant to start empiric steroids without any clear diagnosis\n and some concern for infection.\n 1. Hypoxemic Respiratory Failure - ddx as above. Currently his O2 is\n slowly improving\n - will continue to monitor\n - Treat for infx etiologies\n - obtain sputum if produces\n - Intubate if worsens\n - Will consider bronchoscopy if he improves or he requires intubation\n - Await ANCA, IgE; please make sure anti-GBM is sent\n 2. GI: he has a large patulous esophagus, and there is concern for\n silent aspiration.\n - Will discuss GI if can obtain an esophageal pH probe to evaluate for\n aspiration\n - Start PPI\n - HOB elevated\n 3. ID - Afebrile, but does have leukocytosis. Doubt infectious\n etiology, but favor continuation of antibiotics given clinical status\n - continue vancomycin, levofloxacin, zosyn\n - Please send LDH\n - B glucan/galactommanan\n - Sputum culture if possible; send for routine culture/gram stain;\n PCP, stain/culture\n 4. FEN:\n - will need NGT placement once oxygenation improves\n 5. Psych: Has significant anxiety; not clear if anxiety is secondary to\n his hypoxemia. He is chronically on xanax.\n - If requires additional medications for anxiety, would trial of haldol\n or zyprexa.\n - Can continue home dose of xanax with careful monitoring.\n ICU Care\n Nutrition:\n Holding enteral feeds pending\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 01:22 PM\n 20 Gauge - 01:23 PM\n Comments:\n Prophylaxis:\n DVT: Heparin drip for DVT\n Stress ulcer: PPI\n Communication: Comments: Spoke with family, communicated plan\n Code status: FULL CODE\n Disposition: ICU\n Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2164-02-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 369807, "text": "Chief Complaint: dyspnea; abnormal chest CT\n 24 Hour Events:\n Waxing and oxygen overnight. Significant anxiety requiring\n xanax. Also, he complains of severe pain, given fentanyl IV.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Vancomycin - 10:27 PM\n Piperacillin - 12:17 AM\n Infusions:\n Heparin Sodium - 2,100 units/hour\n Other ICU medications:\n Heparin Sodium - 04:56 PM\n Fentanyl - 07:56 AM\n Other medications:\n Heparin drip\n Duragesic patch\n Mexilitine\n Levofloxacin 750mg IV daily\n colace\n Uroqid\n Mucinex\n Baclofen\n Zinc\n Omeprazole 20mg daily\n Methadone 20mg \n Synthroid\n Lactulose\n Atrovent\n Fexofenadine\n Zosyn\n Vancomycin\n Wellbutrin\n Polyethylene glycol\n Theophylline\n MVI\n Vitamin C\n Changes to medical and family history:\n No change from admission\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.7\nC (96.3\n HR: 98 (86 - 108) bpm\n BP: 128/70(86) {110/55(67) - 135/75(88)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 640 mL\n 392 mL\n PO:\n TF:\n IVF:\n 640 mL\n 392 mL\n Blood products:\n Total out:\n 1,630 mL\n 580 mL\n Urine:\n 1,630 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -990 mL\n -188 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin, cachectic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Crackles : bilateral bases)\n Abdominal: Soft\n Extremities: Right: Trace, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 603 K/uL\n 161 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.0 mEq/L\n 6 mg/dL\n 91 mEq/L\n 134 mEq/L\n 28.1 %\n 15.2 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n WBC\n 13.6\n 15.2\n Hct\n 28.5\n 28.1\n Plt\n 633\n 603\n Cr\n 0.5\n 0.7\n TropT\n 0.02\n Glucose\n 104\n 161\n Other labs: PT / PTT / INR:18.9/66.2/1.7, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 62M with history of transverse myelitis; admitted with dyspnea and new\n bilateral ground glass opacities on chest CT. Unclear etiology, but\n concerning for possible ILD versus aspiration.\n 1. Hypoxemia: as noted in admission note, broad differential.\n - Will repeat CBC differential to re-evaluate for eosinophils\n - Await ANCA, , GBM, IgE\n - Send glucan and galactommanan\n - SPEP/UPEP\n - Sputum if able to obtain\n - For time being will hold on bronchoscopy, wait another 24-48h and\n follow clinically. Will possibly require intubation and bronchoscopy\n but should have discussion with him and family regarding potential for\n prolonged ventilation\n 2. Pain: he has chronic lower back pain, is increasing in severity.\n The etiology is unclear, but likely complicated by constipation now.\n - Improve bowel regimen\n - When stable from pulmonary standpoint would evaluate with MRI or CT\n of lumbar spine.\n - Geriatric-psych consult for behavior issues\n 3. GI:\n - will need evaluation of aspiration, with pH probe. Plan to discuss\n - Increase dose of omeprazole to 40mg daily\n - Will discuss placement of NGT with patient; he has had a history of\n sinus surgery and should review history first.\n 4. DVT\n - on heparin drip\n ICU Care\n Nutrition: Currently NPO\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 04:51 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:27 ------\n" }, { "category": "Nursing", "chartdate": "2164-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369815, "text": "HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum\n .H/O anxiety\n Assessment:\n Pt very anxious this am calling out stating he was having anxiety\n wanting more xanax,\n Action:\n Pt medicatated with another .125 mg po\n Response:\n Fair response with anxiety med\n Plan:\n To mucuh delay in getting extra dose and pt wasa too worked up by the\n time he got the dose for it to work well\n Pt seen by and palliative care today, plan to give xanax .125\n q4 and hold for pt being too somulent\n Chronic Pain\n Assessment:\n Pt also this am was c/o sever pain stated that patch was not\n working , asked for fent lollypop at the time but then told me he was\n unable to hold it in his mouth, was offered fentanyl iv but then\n refused,\n Action:\n Pt eventually allowed up to medicated him with fent 12.5 x2 and then\n needed an extra dose an house later\n Response:\n By 10 am pt had pain relief\n Plan:\n We will not use fent 12.5-25 prn as needed I think at baseline he will\n need to be dosed q6 and we should try to encourage him to take bolus\n doses , if we can manage his pain better we may be able to break the\n pain anxiety cycle, palliative care following , the above are the\n recommendations we will try with pt he is very resistant to change pain\n meds\n Hypoxemia\n Assessment:\n Pt has been on 100% nrb most of the day sats 88-100 depending on who\n anxious, lungs cta,\n Action:\n Pt receiving nebs q6\n Response:\n Not able to break mask with out sats dropping , no pulmonary reserve\n with any care will desat and takes 10-15 minutes to recove,\n Plan:\n Family and primary care would like to try bipap, pt has been\n premedicated but very conserned about trying mask , he has a hx of\n being able to tolerated bipap, pt is already working himself up prior\n to us even placing him on the mask resident will speak with the family\n in this reguards\n Alteration in Nutrition\n Assessment:\n Pt taking clear liquids, no solid food, and maybe several spoonfuls of\n tofu\n Action:\n Poor po intake\n Response:\n No interest in food\n Plan:\n We have addressed the need for feeds with wife and pt, ngt in not an\n option with septal wrok that has been done other option my be peg but\n not sure it pt will allow, have spoke with resident and feel that we\n should try ppn , have iv therapy try a mid line tomorrow\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt L hip ulcer dsg changed this am had large amounts of sereous.pussy\n drainage that is fowel smelling\n Action:\n Pt had area cleaned with would cleanser and pack with n/s ,\n Response:\n Plan:\n Plan to have plastics to see wound in am\n Pt remains on heparin drip at 2100u/hr\n Plan is to have primary care come in tomorrow and address goals of care\n with patient, Pt does have issues with trust and it is felt that the\n primary has such a close relationship with pt and family that he will\n be able to address these issues better with the patient.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369904, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment.\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given.\n Hallodol 2 mg IV X1 given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware. RR at 16-20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Physician ", "chartdate": "2164-02-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369789, "text": "TITLE:\n Chief Complaint: Dyspnea\n 24 Hour Events:\n Transferred back to ICU for frequent desating to 60s requiring NRB, no\n fever, persistent leukocytosis, on broad-spectrum abx\n - monitor for now; will not electively intubate for bronch (for now)\n - talked to GI re: possible esophageal pH probe; GI recommended upper\n GI series first and then endoscopy\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Vancomycin - 10:27 PM\n Piperacillin - 12:17 AM\n Infusions:\n Heparin Sodium - 2,100 units/hour\n Other ICU medications:\n Heparin Sodium - 04:56 PM\n Fentanyl - 07:56 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Cardiovascular: Tachycardia\n Respiratory: Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: LE\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.7\nC (96.3\n HR: 93 (86 - 108) bpm\n BP: 125/73(82) {110/55(67) - 135/75(85)} mmHg\n RR: 19 (15 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 640 mL\n 348 mL\n PO:\n TF:\n IVF:\n 640 mL\n 348 mL\n Blood products:\n Total out:\n 1,630 mL\n 580 mL\n Urine:\n 1,630 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -990 mL\n -232 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Musculoskeletal: Unable to stand, paraplegic\n Skin: Warm, sacral decubitus ulcer\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 603 K/uL\n 9.1 g/dL\n 161 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.0 mEq/L\n 6 mg/dL\n 91 mEq/L\n 134 mEq/L\n 28.1 %\n 15.2 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n WBC\n 13.6\n 15.2\n Hct\n 28.5\n 28.1\n Plt\n 633\n 603\n Cr\n 0.5\n 0.7\n TropT\n 0.02\n Glucose\n 104\n 161\n Other labs: PT / PTT / INR:18.9/66.2/1.7, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n H/O ANXIETY\n ALTERATION IN NUTRITION\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx\n - consider elective intubation for bronch\n - hold off on diuresis for now\n - consider bronch\n .\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - gentle diuresis\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n - palliative care consult\n - -psych c/s\n - prn fentanyl\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ NGT for TFs (if\n amenable)\n .\n # PPX: PPI, heparin gtt, bowel regimen\n .\n # ACCESS: PIV\n .\n # CODE: Full\n .\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 04:51 AM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-02-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 369804, "text": "Chief Complaint: dyspnea; abnormal chest CT\n 24 Hour Events:\n Waxing and oxygen overnight. Significant anxiety requiring\n xanax. Also, he complains of severe pain, given fentanyl IV.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Vancomycin - 10:27 PM\n Piperacillin - 12:17 AM\n Infusions:\n Heparin Sodium - 2,100 units/hour\n Other ICU medications:\n Heparin Sodium - 04:56 PM\n Fentanyl - 07:56 AM\n Other medications:\n Heparin drip\n Duragesic patch\n Mexilitine\n Levofloxacin 750mg IV daily\n colace\n Uroqid\n Mucinex\n Baclofen\n Zinc\n Omeprazole 20mg daily\n Methadone 20mg \n Synthroid\n Lactulose\n Atrovent\n Fexofenadine\n Zosyn\n Vancomycin\n Wellbutrin\n Polyethylene glycol\n Theophylline\n MVI\n Vitamin C\n Changes to medical and family history:\n No change from admission\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.7\nC (96.3\n HR: 98 (86 - 108) bpm\n BP: 128/70(86) {110/55(67) - 135/75(88)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 640 mL\n 392 mL\n PO:\n TF:\n IVF:\n 640 mL\n 392 mL\n Blood products:\n Total out:\n 1,630 mL\n 580 mL\n Urine:\n 1,630 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -990 mL\n -188 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin, cachectic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Crackles : bilateral bases)\n Abdominal: Soft\n Extremities: Right: Trace, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 603 K/uL\n 161 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.0 mEq/L\n 6 mg/dL\n 91 mEq/L\n 134 mEq/L\n 28.1 %\n 15.2 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n WBC\n 13.6\n 15.2\n Hct\n 28.5\n 28.1\n Plt\n 633\n 603\n Cr\n 0.5\n 0.7\n TropT\n 0.02\n Glucose\n 104\n 161\n Other labs: PT / PTT / INR:18.9/66.2/1.7, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 62M with history of transverse myelitis; admitted with dyspnea and new\n bilateral ground glass opacities on chest CT. Unclear etiology, but\n concerning for possible ILD versus aspiration.\n 1. Hypoxemia: as noted in admission note, broad differential.\n - Will repeat CBC differential to re-evaluate for eosinophils\n - Await ANCA, , GBM, IgE\n - Send glucan and galactommanan\n - SPEP/UPEP\n - Sputum if able to obtain\n - For time being will hold on bronchoscopy, wait another 24-48h and\n follow clinically. Will possibly require intubation and bronchoscopy\n but should have discussion with him and family regarding potential for\n prolonged ventilation\n 2. Pain: he has chronic lower back pain, is increasing in severity.\n The etiology is unclear, but likely complicated by constipation now.\n - Improve bowel regimen\n - When stable from pulmonary standpoint would evaluate with MRI or CT\n of lumbar spine.\n - Geriatric-psych consult for behavior issues\n 3. GI:\n - will need evaluation of aspiration, with pH probe. Plan to discuss\n - Increase dose of omeprazole to 40mg daily\n - Will discuss placement of NGT with patient; he has had a history of\n sinus surgery and should review history first.\n 4. DVT\n - on heparin drip\n ICU Care\n Nutrition: Currently NPO\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 04:51 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369906, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, started on\n halodol 2 mg IV as PRN basis. Geriatric consulted. Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment.\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given.\n Hallodol 2 mg IV X1 given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware. RR at 16-20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs, pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369909, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, started on\n halodol 2 mg IV as PRN basis. Geriatric consulted. Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment.\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given.\n Hallodol 2 mg IV X1 given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware. RR at 16-20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs, pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Physician ", "chartdate": "2164-02-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 369449, "text": "Chief Complaint: Shortness of breath\n HPI:\n 62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. The\n patient has had a complicated recent history involving a tib/fib fx\n sustained while moving in his wheel chair. This was not treated\n surgically. He also has a sacral decub which was treated with 2 weeks\n of cipro then 2 weeks of levofloxacin. Over the past two days he has\n been having increasing shortness of breath. He has oxygen at home which\n he normally does not use. He has been using up to 4L 1 day PTA. He\n reports no fevers of chills. He has been taking his temp and no\n documented fevers. He does not endorse ant chest pain. His wife notes\n that although his right leg is constantly swollen from the fracture,\n his left leg has been having increasing swelling over the past few\n days. His wife also notes that he has been increasingly lethargic over\n the past few days as well.\n .\n In the ED, he recieved Vanc and Zosyn. CTA neg for PE but showed no\n central PE but bibasal GGO and more consolidative opc w/enlarged\n subcarinal ? pna (preliminary read). The Medicine housetaff\n discussed scan with Pulmonary, who felt this scan likely represented\n aspiration, or CHF, less likely ILD.\n .\n Upon arrival to the medicine floor his sats were in the 80s on NC and\n he required a NRB to attain sats in the 90s. An ABG was performed\n 7.49/44/141. He was given 20mg IV lasix. He was eventually able to be\n placed on a 40% venturi mask. His oral temp was 99.7. He was short of\n breath when not on the NRB. The patient is being transferred to the\n MICU for higher level of nursing care and closer monitoring given\n fluctuating oxygen requirement.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain,\n nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,\n dysuria, hematuria.\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n TRANSVERSE MYELITIS: virus in 90s.\n CHRONIC PAIN\n CHRONIC UTI\n NEUROGENIC BLADDER\n DEPRESSION\n ASTHMA\n CONSTIPATION\n NASAL POLYPS\n BURSITIS - R HIP\n DECUBITUS ULCER\n SYNDROME\n Non-contributory\n Occupation: None\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Lives with wife who is primary caretaker\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, Edema, No(t) Orthopnea\n Respiratory: Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice, erythema legs B\n Neurologic: hx paraplegia\n Pain: Minimal\n Pain location: decubiti\n Flowsheet Data as of 02:25 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 103 (103 - 117) bpm\n BP: 109/65(73) {109/65(73) - 120/75(83)} mmHg\n RR: 14 (14 - 22) insp/min\n SpO2: 100%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -500 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 100%\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, anicteric\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Fine, scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, erythema/warmth scattered on both\n legs\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 686\n 149\n 0.5\n 5\n 31\n 90\n 3.9\n 129\n 29.3\n 16.4\n [image002.jpg]\n Other labs: Differential-Neuts:87.3, Lactic Acid:1.1\n Fluid analysis / Other labs: BNP 722\n CK/trop neg x 2\n ABG: 7.49/44/141/34\n Imaging: Chest CT: CTA neg for PE but showed no central PE but Bibasal\n GGO and more consolidative opc w/enlarged subcarinal ? pna.\n Microbiology: Blood cx: P\n Urine cx : P\n Sputum cx: P\n ECG: ST NA/NI, NSST-T changes similar to prior\n Assessment and Plan\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: CTA r/o PE but showed mostly dependent GGO, ? aspiration\n PNA/pneumonitis vs CAP vs ILD (less likely as spares apices) vs\n pulmonary edema. Leukocytosis of 16.4, lactate 1.1. No wheezing to\n suggest asthma exacerbation. There has been some concern in the past of\n the pt aspirating.\n - Vanco/Zosyn/levaquin for now, then narrow\n - Sputum cx\n - Pulmonary c/s in AM (already reviewed CT scans)\n - F/U final read of CT scan\n - Cautious diuresis, pt has improved after diuresis on floor\n - Would hold on steroids for now as likely infectious\n - Formal S&S eval in AM\n .\n # LE Edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n - Vanco will cover cellulitis\n - LENIs to r/o DVT\n - Gentle diuresis\n - Check albumin\n - TTE tomorrow for cardiac function\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was with levaquin as outpatient, scheduled for Plastics\n eval tomorrow as outpatient.\n - Wound care consult in AM\n - Plastics consult\n - Current antibiotics should cover for now\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n .\n # PPX: PPI, heparin SQ, bowel regimen\n .\n # ACCESS: PIV\n .\n # CODE: Full\n .\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n .\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines: PIV\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-02-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 369790, "text": "Chief Complaint: dyspnea; abnormal chest CT\n 24 Hour Events:\n Waxing and oxygen overnight. Significant anxiety requiring\n xanax. Also, he complains of severe pain, given fentanyl IV.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Vancomycin - 10:27 PM\n Piperacillin - 12:17 AM\n Infusions:\n Heparin Sodium - 2,100 units/hour\n Other ICU medications:\n Heparin Sodium - 04:56 PM\n Fentanyl - 07:56 AM\n Other medications:\n Heparin drip\n Duragesic patch\n Mexilitine\n Levofloxacin 750mg IV daily\n colace\n Uroqid\n Mucinex\n Baclofen\n Zinc\n Omeprazole 20mg daily\n Methadone 20mg \n Synthroid\n Lactulose\n Atrovent\n Fexofenadine\n Zosyn\n Vancomycin\n Wellbutrin\n Polyethylene glycol\n Theophylline\n MVI\n Vitamin C\n Changes to medical and family history:\n No change from admission\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.7\nC (96.3\n HR: 98 (86 - 108) bpm\n BP: 128/70(86) {110/55(67) - 135/75(88)} mmHg\n RR: 18 (15 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 640 mL\n 392 mL\n PO:\n TF:\n IVF:\n 640 mL\n 392 mL\n Blood products:\n Total out:\n 1,630 mL\n 580 mL\n Urine:\n 1,630 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -990 mL\n -188 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin, cachectic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Crackles : bilateral bases)\n Abdominal: Soft\n Extremities: Right: Trace, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 603 K/uL\n 161 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.0 mEq/L\n 6 mg/dL\n 91 mEq/L\n 134 mEq/L\n 28.1 %\n 15.2 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n WBC\n 13.6\n 15.2\n Hct\n 28.5\n 28.1\n Plt\n 633\n 603\n Cr\n 0.5\n 0.7\n TropT\n 0.02\n Glucose\n 104\n 161\n Other labs: PT / PTT / INR:18.9/66.2/1.7, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 62M with history of transverse myelitis; admitted with dyspnea and new\n bilateral ground glass opacities on chest CT. Unclear etiology, but\n concerning for possible ILD versus aspiration.\n 1. Hypoxemia: as noted in admission note, broad differential.\n - Will repeat CBC differential to re-evaluate for eosinophils\n - Await ANCA, , GBM, IgE\n - Send glucan and galactommanan\n - SPEP/UPEP\n - Sputum if able to obtain\n - For time being will hold on bronchoscopy, wait another 24-48h and\n follow clinically. Will possibly require intubation and bronchoscopy\n but should have discussion with him and family regarding potential for\n prolonged ventilation\n 2. Pain: he has chronic lower back pain, is increasing in severity.\n The etiology is unclear, but likely complicated by constipation now.\n - Improve bowel regimen\n - When stable from pulmonary standpoint would evaluate with MRI or CT\n of lumbar spine.\n - Geriatric-psych consult for behavior issues\n 3. GI:\n - will need evaluation of aspiration, with pH probe. Plan to discuss\n - Increase dose of omeprazole to 40mg daily\n - Will discuss placement of NGT with patient; he has had a history of\n sinus surgery and should review history first.\n 4. DVT\n - on heparin drip\n ICU Care\n Nutrition: Currently NPO\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 04:51 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2164-02-19 00:00:00.000", "description": "PT Contact Note", "row_id": 369795, "text": "TITLE: PT/Rehab Services\n Patient had been on PT service when floor status seen for chest PT.\n Now transferred to MICU. Met with RN to discuss whether patient\n appropriate to follow currently. She felt that due to his pain and\n anxiety he would not be able to tolerate any treatment. We will keep\n this patient on service and continue to check in and follow as\n appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369892, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment.\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369888, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n Today, PCP to come in and discuss hospice care with pt and family;\n overnight, pt refusing all PO\ns except ice chips\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting 100% currently, RR teens, regular, appears comfortable, LS now\n with RUL rhonchi\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax;\n tonight pt had episode where he became agitated and anxious, requesting\n a\nshot for panic\n , yelling out, unable to calm pt, desatting to 80\n RR to 30\n Action:\n Pt family called to be at patient\ns bedside, given prn fentanyl and one\n time order of ativan; attemped to administer patient\ns standing xanax\n and methadone throughout shift but pt refusing\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse xanax, also unable to give all other PO meds, MD\n aware\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @ 2100 units/hr, +PP bilaterally,\n bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT therapeutic, 82.6\n Response:\n PTT @ 4a >150, gtt off x1h, resuming at 1900units/hr\n Plan:\n Q6h PTT, gtt therapeutic, goal 60-100\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, started D5\n @ 100cc/hr x 500cc\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 100cc/hr\n" }, { "category": "Physician ", "chartdate": "2164-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369877, "text": "TITLE:\n Chief Complaint: Respiratory distress\n 24 Hour Events:\n - PCP . called: suggests CPAP trial if possible but thinks\n patient will be unlikely to tolerate mask unless Clonazepam loaded (pt\n states he's tolerated in the past for approximately 30 seconds); agrees\n that intubation may not be helpful for longterm goals but thinks PEG\n may be necessary and that family would agree\n - Palliative / Pain consult: suggest scheduled Alprazolam 0.125 Q4H (pt\n may refuse); Fentanyl 12.5-25mcg IV q4H (pt may refuse); contact Dr.\n and see if he will be able to visit patient in hospital, also need\n to clarify if longterm goals have been discussed as outpatient with\n family\n - Geriatrics consult: Would recommend Celexa instead of Wellbutrin,\n schedule alprazolam, contact PCP\n CBC with diff obtain: no eosiniophilia or significant change\n - NGT not placed given h/o nasal surgery\n - PEG not pursued given tenuous respiratory status\n - Anti-GBM, SPEP, UPEP sent\n - Pt taking minimal pos, changed po Alprazolam to IV Ativan\n - Medications changed to IV for less po dosing: Synthroid, PPI\n - Started refusing po anxiolytics; given Ativan 0.5mg IV x 2\n - Per discussion with family & patient, will change code status to\n DNR/DNI as patient would never want a trach and his functional status\n is already poor; if no hope for improved functional status, would\n prefer home with hospice\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Piperacillin - 04:16 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Heparin Sodium - 1,900 units/hour\n Other ICU medications:\n Fentanyl - 07:41 PM\n Lorazepam (Ativan) - 07:45 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, Tachypnea\n Genitourinary: Foley\n Integumentary (skin): decubitus ulcer\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.4\nC (95.8\n HR: 99 (91 - 118) bpm\n BP: 125/53(70) {104/53(68) - 131/83(90)} mmHg\n RR: 15 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,318 mL\n 888 mL\n PO:\n TF:\n IVF:\n 2,318 mL\n 888 mL\n Blood products:\n Total out:\n 2,110 mL\n 750 mL\n Urine:\n 1,710 mL\n 750 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 208 mL\n 138 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Distended\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 589 K/uL\n 9.5 g/dL\n 154 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 11 mg/dL\n 101 mEq/L\n 138 mEq/L\n 29.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n WBC\n 13.6\n 15.2\n 16.1\n Hct\n 28.5\n 28.1\n 29.3\n Plt\n 633\n 603\n 589\n Cr\n 0.5\n 0.7\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n Other labs: PT / PTT / INR:23.1/150.0/2.2, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:75.0 %, Band:0.0 %, Lymph:6.0 %, Mono:13.0 %,\n Eos:4.0 %, Albumin:2.6 g/dL, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx (not currently producing sputum)\n - consider elective intubation for bronch but given pt adamantly DNI\n given possible need for trach, no bronch; also bronch would be\n difficult given desaturations\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - gentle diuresis\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n - palliative care consult\n - -psych c/s\n - prn fentanyl\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ NGT for TFs (if\n amenable)\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: PPI IV\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 369879, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Returned to ICU from the floor due to needing high O2 req, 7.49/44/141\n on NRB. After discussion with family they decided to make him DNR/DNI\n and no bronch due to risk of needing long term ventilation.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Levofloxacin - 08:10 AM\n Vancomycin - 08:40 AM\n Infusions:\n Heparin Sodium - 1,900 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 07:45 PM\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 111 (91 - 118) bpm\n BP: 129/58(74) {104/53(68) - 129/83(90)} mmHg\n RR: 30 (11 - 32) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,318 mL\n 1,613 mL\n PO:\n TF:\n IVF:\n 2,318 mL\n 1,613 mL\n Blood products:\n Total out:\n 2,110 mL\n 810 mL\n Urine:\n 1,710 mL\n 810 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 208 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : diffusely, Wheezes : diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): X3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 589 K/uL\n 154 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 11 mg/dL\n 101 mEq/L\n 138 mEq/L\n 29.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n WBC\n 13.6\n 15.2\n 16.1\n Hct\n 28.5\n 28.1\n 29.3\n Plt\n 633\n 603\n 589\n Cr\n 0.5\n 0.7\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n Other labs: PT / PTT / INR:23.1/150.0/2.2, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:75.0 %, Band:0.0 %, Lymph:6.0 %, Mono:13.0 %,\n Eos:4.0 %, Albumin:2.6 g/dL, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 1. Diffuse parenchymal lung disease:\n -complete tx for PNA\n -start solumedrol 60 mg IV daily for possible inflammatory disease\n given we will not persue bronch or bx\n -IgE level\n -f/ /ANCA/antiGBM\n 2. DVT:\n -heparin gtt\n 3. Sacral decub:\n -on abx\n -cont. IV pain regimen\n 4. Pain/anxiety:\n -cont. IV opiates and benzos\n -geripsyche recs\n 5. FEN: refusing pos for now, consider IV nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2164-02-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369984, "text": "TITLE:\n Chief Complaint: shortness of breath\n 24 Hour Events:\n - recs: Remeron solutab 15mg PO qHS\n - Met with PCP : start Haldol\n - Nutrition plan: wife OK with TPN if needed, no PEG, no NGT\n - Vanco trough 21 at 3 AM and dosed at 8 & 8, gave Vanco 750 x 1,\n trough 7 AM\n - Watch creatinine, slowly trending up\n - ANCA, , UPEP: neg\n - SPEP, IGE, ACE, anti-GBM: P\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Levofloxacin - 08:10 AM\n Vancomycin - 10:11 PM\n Piperacillin/Tazobactam (Zosyn) - 12:28 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Lorazepam (Ativan) - 01:27 AM\n Fentanyl - 05:47 AM\n Haloperidol (Haldol) - 06:48 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Genitourinary: Foley\n Heme / Lymph: Anemia, Coagulopathy\n Psychiatric / Sleep: Agitated\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 100 (93 - 111) bpm\n BP: 131/78(89) {106/58(73) - 144/86(94)} mmHg\n RR: 28 (17 - 35) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,145 mL\n 787 mL\n PO:\n TF:\n IVF:\n 3,145 mL\n 787 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n Drains:\n Balance:\n 1,720 mL\n 297 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed, ulceration\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 561 K/uL\n 10.6 g/dL\n 154 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.4 mEq/L\n 14 mg/dL\n 99 mEq/L\n 137 mEq/L\n 33.5 %\n 18.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n Plt\n 633\n 603\n 589\n 561\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n Other labs: PT / PTT / INR:24.2/71.3/2.4, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx (not currently producing sputum)\n - consider elective intubation for bronch but given pt adamantly DNI\n given possible need for trach, no bronch; also bronch would be\n difficult given desaturations\n - steroids (Solumedrol 60mg IV QD)\n - some coughing over last 24H, try to obtain sputum sample\n - CXR this AM\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - run even\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fentanyl.\n - Continue meds cautiously given resp status\n - palliative care consult:\n - -psych c/s: start remeron\n - prn fentanyl\n - continue IV ativan, IV haldol, IV fentanyl\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ NGT for TFs (if\n amenable)\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: Wife\n .\n # DISPO: ICU for now vs home with hospice\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU vs home with hospice\n" }, { "category": "Physician ", "chartdate": "2164-02-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 369985, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n , ANCA neg. Started steroids yesterday.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Vancomycin - 10:11 PM\n Piperacillin/Tazobactam (Zosyn) - 07:59 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:47 AM\n Pantoprazole (Protonix) - 09:00 AM\n Haloperidol (Haldol) - 09:00 AM\n Lorazepam (Ativan) - 10:20 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.3\nC (95.6\n HR: 100 (93 - 108) bpm\n BP: 118/77(87) {106/59(73) - 144/86(94)} mmHg\n RR: 21 (17 - 35) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,145 mL\n 1,227 mL\n PO:\n TF:\n IVF:\n 3,145 mL\n 1,227 mL\n Blood products:\n Total out:\n 1,425 mL\n 685 mL\n Urine:\n 1,425 mL\n 685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,720 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : , Wheezes : diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 561 K/uL\n 110 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 16 mg/dL\n 98 mEq/L\n 141 mEq/L\n 33.5 %\n 18.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n Plt\n 633\n 603\n 589\n 561\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n 1.2\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n 110\n Other labs: PT / PTT / INR:24.2/71.3/2.4, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.9 mg/dL, Mg++:2.3 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n Plan:\n 1. Hypoxemia: Started on steroids on interstitial disease\n -recheck CXR\n -change NRB to air to get RA sat\n -refusing nebs\n 2. DVT: Cont. heparin\n 3. Cellulitis:\n -vancomycin\n 4. pain: methadone/fentanyl\n -geripsyche recs\n 5. FEN: discuss PICC line for TPN with patient\n -refusing po diet\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2164-02-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369777, "text": "TITLE:\n Chief Complaint: Dyspnea\n 24 Hour Events:\n Transferred back to ICU for frequent desating to 60s requiring NRB, no\n fever, persistent leukocytosis, on broad-spectrum abx\n - monitor for now; will not electively intubate for bronch (for now)\n - talked to GI re: possible esophageal pH probe; GI recommended upper\n GI series first and then endoscopy\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Vancomycin - 10:27 PM\n Piperacillin - 12:17 AM\n Infusions:\n Heparin Sodium - 2,100 units/hour\n Other ICU medications:\n Heparin Sodium - 04:56 PM\n Fentanyl - 07:56 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Cardiovascular: Tachycardia\n Respiratory: Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: LE\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.7\nC (96.3\n HR: 93 (86 - 108) bpm\n BP: 125/73(82) {110/55(67) - 135/75(85)} mmHg\n RR: 19 (15 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 640 mL\n 348 mL\n PO:\n TF:\n IVF:\n 640 mL\n 348 mL\n Blood products:\n Total out:\n 1,630 mL\n 580 mL\n Urine:\n 1,630 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -990 mL\n -232 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Musculoskeletal: Unable to stand, paraplegic\n Skin: Warm, sacral decubitus ulcer\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 603 K/uL\n 9.1 g/dL\n 161 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.0 mEq/L\n 6 mg/dL\n 91 mEq/L\n 134 mEq/L\n 28.1 %\n 15.2 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n WBC\n 13.6\n 15.2\n Hct\n 28.5\n 28.1\n Plt\n 633\n 603\n Cr\n 0.5\n 0.7\n TropT\n 0.02\n Glucose\n 104\n 161\n Other labs: PT / PTT / INR:18.9/66.2/1.7, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n .H/O ANXIETY\n ALTERATION IN NUTRITION\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 04:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369778, "text": "TITLE:\n Chief Complaint: Dyspnea\n 24 Hour Events:\n Transferred back to ICU for frequent desating to 60s requiring NRB, no\n fever, persistent leukocytosis, on broad-spectrum abx\n - monitor for now; will not electively intubate for bronch (for now)\n - talked to GI re: possible esophageal pH probe; GI recommended upper\n GI series first and then endoscopy\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Vancomycin - 10:27 PM\n Piperacillin - 12:17 AM\n Infusions:\n Heparin Sodium - 2,100 units/hour\n Other ICU medications:\n Heparin Sodium - 04:56 PM\n Fentanyl - 07:56 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Cardiovascular: Tachycardia\n Respiratory: Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: LE\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.7\nC (96.3\n HR: 93 (86 - 108) bpm\n BP: 125/73(82) {110/55(67) - 135/75(85)} mmHg\n RR: 19 (15 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 640 mL\n 348 mL\n PO:\n TF:\n IVF:\n 640 mL\n 348 mL\n Blood products:\n Total out:\n 1,630 mL\n 580 mL\n Urine:\n 1,630 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -990 mL\n -232 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Musculoskeletal: Unable to stand, paraplegic\n Skin: Warm, sacral decubitus ulcer\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 603 K/uL\n 9.1 g/dL\n 161 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.0 mEq/L\n 6 mg/dL\n 91 mEq/L\n 134 mEq/L\n 28.1 %\n 15.2 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n WBC\n 13.6\n 15.2\n Hct\n 28.5\n 28.1\n Plt\n 633\n 603\n Cr\n 0.5\n 0.7\n TropT\n 0.02\n Glucose\n 104\n 161\n Other labs: PT / PTT / INR:18.9/66.2/1.7, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:9.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n H/O ANXIETY\n ALTERATION IN NUTRITION\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx\n - consider elective intubation for bronch\n - hold off on diuresis for now\n .\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - gentle diuresis\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n .\n # PPX: PPI, heparin gtt, bowel regimen\n .\n # ACCESS: PIV\n .\n # CODE: Full\n .\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 04:51 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369856, "text": "TITLE:\n Chief Complaint: Respiratory distress\n 24 Hour Events:\n - PCP . called: suggests CPAP trial if possible but thinks\n patient will be unlikely to tolerate mask unless Clonazepam loaded (pt\n states he's tolerated in the past for approximately 30 seconds); agrees\n that intubation may not be helpful for longterm goals but thinks PEG\n may be necessary and that family would agree\n - Palliative / Pain consult: suggest scheduled Alprazolam 0.125 Q4H (pt\n may refuse); Fentanyl 12.5-25mcg IV q4H (pt may refuse); contact Dr.\n and see if he will be able to visit patient in hospital, also need\n to clarify if longterm goals have been discussed as outpatient with\n family\n - Geriatrics consult: Would recommend Celexa instead of Wellbutrin,\n schedule alprazolam, contact PCP\n CBC with diff obtain: no eosiniophilia or significant change\n - NGT not placed given h/o nasal surgery\n - PEG not pursued given tenuous respiratory status\n - Anti-GBM, SPEP, UPEP sent\n - Pt taking minimal pos, changed po Alprazolam to IV Ativan\n - Medications changed to IV for less po dosing: Synthroid, PPI\n - Started refusing po anxiolytics; given Ativan 0.5mg IV x 2\n - Per discussion with family & patient, will change code status to\n DNR/DNI as patient would never want a trach and his functional status\n is already poor; if no hope for improved functional status, would\n prefer home with hospice\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Piperacillin - 04:16 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Heparin Sodium - 1,900 units/hour\n Other ICU medications:\n Fentanyl - 07:41 PM\n Lorazepam (Ativan) - 07:45 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, Tachypnea\n Genitourinary: Foley\n Integumentary (skin): decubitus ulcer\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.4\nC (95.8\n HR: 99 (91 - 118) bpm\n BP: 125/53(70) {104/53(68) - 131/83(90)} mmHg\n RR: 15 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,318 mL\n 888 mL\n PO:\n TF:\n IVF:\n 2,318 mL\n 888 mL\n Blood products:\n Total out:\n 2,110 mL\n 750 mL\n Urine:\n 1,710 mL\n 750 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 208 mL\n 138 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Distended\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 589 K/uL\n 9.5 g/dL\n 154 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 11 mg/dL\n 101 mEq/L\n 138 mEq/L\n 29.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n WBC\n 13.6\n 15.2\n 16.1\n Hct\n 28.5\n 28.1\n 29.3\n Plt\n 633\n 603\n 589\n Cr\n 0.5\n 0.7\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n Other labs: PT / PTT / INR:23.1/150.0/2.2, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:75.0 %, Band:0.0 %, Lymph:6.0 %, Mono:13.0 %,\n Eos:4.0 %, Albumin:2.6 g/dL, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369857, "text": "TITLE:\n Chief Complaint: Respiratory distress\n 24 Hour Events:\n - PCP . called: suggests CPAP trial if possible but thinks\n patient will be unlikely to tolerate mask unless Clonazepam loaded (pt\n states he's tolerated in the past for approximately 30 seconds); agrees\n that intubation may not be helpful for longterm goals but thinks PEG\n may be necessary and that family would agree\n - Palliative / Pain consult: suggest scheduled Alprazolam 0.125 Q4H (pt\n may refuse); Fentanyl 12.5-25mcg IV q4H (pt may refuse); contact Dr.\n and see if he will be able to visit patient in hospital, also need\n to clarify if longterm goals have been discussed as outpatient with\n family\n - Geriatrics consult: Would recommend Celexa instead of Wellbutrin,\n schedule alprazolam, contact PCP\n CBC with diff obtain: no eosiniophilia or significant change\n - NGT not placed given h/o nasal surgery\n - PEG not pursued given tenuous respiratory status\n - Anti-GBM, SPEP, UPEP sent\n - Pt taking minimal pos, changed po Alprazolam to IV Ativan\n - Medications changed to IV for less po dosing: Synthroid, PPI\n - Started refusing po anxiolytics; given Ativan 0.5mg IV x 2\n - Per discussion with family & patient, will change code status to\n DNR/DNI as patient would never want a trach and his functional status\n is already poor; if no hope for improved functional status, would\n prefer home with hospice\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Piperacillin - 04:16 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Heparin Sodium - 1,900 units/hour\n Other ICU medications:\n Fentanyl - 07:41 PM\n Lorazepam (Ativan) - 07:45 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, Tachypnea\n Genitourinary: Foley\n Integumentary (skin): decubitus ulcer\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.4\nC (95.8\n HR: 99 (91 - 118) bpm\n BP: 125/53(70) {104/53(68) - 131/83(90)} mmHg\n RR: 15 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,318 mL\n 888 mL\n PO:\n TF:\n IVF:\n 2,318 mL\n 888 mL\n Blood products:\n Total out:\n 2,110 mL\n 750 mL\n Urine:\n 1,710 mL\n 750 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 208 mL\n 138 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Distended\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 589 K/uL\n 9.5 g/dL\n 154 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 11 mg/dL\n 101 mEq/L\n 138 mEq/L\n 29.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n WBC\n 13.6\n 15.2\n 16.1\n Hct\n 28.5\n 28.1\n 29.3\n Plt\n 633\n 603\n 589\n Cr\n 0.5\n 0.7\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n Other labs: PT / PTT / INR:23.1/150.0/2.2, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:75.0 %, Band:0.0 %, Lymph:6.0 %, Mono:13.0 %,\n Eos:4.0 %, Albumin:2.6 g/dL, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx\n - consider elective intubation for bronch\n - hold off on diuresis for now\n - consider bronch\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - gentle diuresis\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n - palliative care consult\n - -psych c/s\n - prn fentanyl\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ NGT for TFs (if\n amenable)\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369880, "text": "TITLE:\n Chief Complaint: Respiratory distress\n 24 Hour Events:\n - PCP . called: suggests CPAP trial if possible but thinks\n patient will be unlikely to tolerate mask unless Clonazepam loaded (pt\n states he's tolerated in the past for approximately 30 seconds); agrees\n that intubation may not be helpful for longterm goals but thinks PEG\n may be necessary and that family would agree\n - Palliative / Pain consult: suggest scheduled Alprazolam 0.125 Q4H (pt\n may refuse); Fentanyl 12.5-25mcg IV q4H (pt may refuse); contact Dr.\n and see if he will be able to visit patient in hospital, also need\n to clarify if longterm goals have been discussed as outpatient with\n family\n - Geriatrics consult: Would recommend Celexa instead of Wellbutrin,\n schedule alprazolam, contact PCP\n CBC with diff obtain: no eosiniophilia or significant change\n - NGT not placed given h/o nasal surgery\n - PEG not pursued given tenuous respiratory status\n - Anti-GBM, SPEP, UPEP sent\n - Pt taking minimal pos, changed po Alprazolam to IV Ativan\n - Medications changed to IV for less po dosing: Synthroid, PPI\n - Started refusing po anxiolytics; given Ativan 0.5mg IV x 2\n - Per discussion with family & patient, will change code status to\n DNR/DNI as patient would never want a trach and his functional status\n is already poor; if no hope for improved functional status, would\n prefer home with hospice\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Piperacillin - 04:16 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Heparin Sodium - 1,900 units/hour\n Other ICU medications:\n Fentanyl - 07:41 PM\n Lorazepam (Ativan) - 07:45 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, Tachypnea\n Genitourinary: Foley\n Integumentary (skin): decubitus ulcer\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.4\nC (95.8\n HR: 99 (91 - 118) bpm\n BP: 125/53(70) {104/53(68) - 131/83(90)} mmHg\n RR: 15 (11 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,318 mL\n 888 mL\n PO:\n TF:\n IVF:\n 2,318 mL\n 888 mL\n Blood products:\n Total out:\n 2,110 mL\n 750 mL\n Urine:\n 1,710 mL\n 750 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 208 mL\n 138 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Distended\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 589 K/uL\n 9.5 g/dL\n 154 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 11 mg/dL\n 101 mEq/L\n 138 mEq/L\n 29.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n WBC\n 13.6\n 15.2\n 16.1\n Hct\n 28.5\n 28.1\n 29.3\n Plt\n 633\n 603\n 589\n Cr\n 0.5\n 0.7\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n Other labs: PT / PTT / INR:23.1/150.0/2.2, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:75.0 %, Band:0.0 %, Lymph:6.0 %, Mono:13.0 %,\n Eos:4.0 %, Albumin:2.6 g/dL, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx (not currently producing sputum)\n - consider elective intubation for bronch but given pt adamantly DNI\n given possible need for trach, no bronch; also bronch would be\n difficult given desaturations\n - steroids (Solumedrol 60mg IV QD)\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - run even\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n - palliative care consult\n - -psych c/s\n - prn fentanyl\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ NGT for TFs (if\n amenable)\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: PPI IV\n VAP:\n Comments:\n Communication: Comments: Plan to meet with PCP Dr today with\n family\n Code status: DNR/DNI\n Disposition: ICU\n" }, { "category": "Nutrition", "chartdate": "2164-02-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 369881, "text": "Objective:\n Pertinent medications: Heparin drip, D5 1/2NS with KCl @ 75cc/hr, Abx,\n protonix, others noted\n Labs:\n Value\n Date\n Glucose\n 154 mg/dL\n 03:13 AM\n Glucose Finger Stick\n 168\n 12:00 PM\n BUN\n 11 mg/dL\n 03:13 AM\n Creatinine\n 1.1 mg/dL\n 03:13 AM\n Sodium\n 138 mEq/L\n 03:13 AM\n Potassium\n 3.1 mEq/L\n 03:13 AM\n Chloride\n 101 mEq/L\n 03:13 AM\n TCO2\n 27 mEq/L\n 03:13 AM\n pH (urine)\n 5.0 units\n 05:09 AM\n Albumin\n 2.6 g/dL\n 05:09 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:13 AM\n Phosphorus\n 3.3 mg/dL\n 03:13 AM\n Magnesium\n 1.9 mg/dL\n 03:13 AM\n ALT\n 27 IU/L\n 05:09 AM\n Alkaline Phosphate\n 157 IU/L\n 05:09 AM\n AST\n 39 IU/L\n 05:09 AM\n Total Bilirubin\n 0.3 mg/dL\n 05:09 AM\n WBC\n 16.1 K/uL\n 03:13 AM\n Hgb\n 9.5 g/dL\n 03:13 AM\n Hematocrit\n 29.3 %\n 03:13 AM\n Current diet order / nutrition support: Diet: soft/dysphagia with\n Resource Breeze TID\n Assessment of Nutritional Status\n 62 y.o. M readm to ICU with hypoxemic respiratory failure. Pallative\n care is following pt for pain management. Noted that pt is currently\n refusing po\ns except for ice chips, and has had poor po intake entire\n length of stay, with significant wt loss PTA. Per discussion with MD,\n an NGT placement for TF is not an option due to previous septal work,\n and family does not think that a PEG is an option either. Team is\n planning to further discuss the plan for nutrition with pt and family\n ?today to get a better sense of their wishes. Will follow up with\n plan. Please note that TPN & PPN are not indicated, as pt has a\n functioning GI tract.\n Please page with any ?\ns #\n" }, { "category": "Physician ", "chartdate": "2164-02-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 369883, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Returned to ICU from the floor due to needing high O2 req, 7.49/44/141\n on NRB. After discussion with family they decided to make him DNR/DNI\n and no bronch due to risk of needing long term ventilation.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Levofloxacin - 08:10 AM\n Vancomycin - 08:40 AM\n Infusions:\n Heparin Sodium - 1,900 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 07:45 PM\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 111 (91 - 118) bpm\n BP: 129/58(74) {104/53(68) - 129/83(90)} mmHg\n RR: 30 (11 - 32) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,318 mL\n 1,613 mL\n PO:\n TF:\n IVF:\n 2,318 mL\n 1,613 mL\n Blood products:\n Total out:\n 2,110 mL\n 810 mL\n Urine:\n 1,710 mL\n 810 mL\n NG:\n 400 mL\n Stool:\n Drains:\n Balance:\n 208 mL\n 803 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : diffusely, Wheezes : diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): X3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 589 K/uL\n 154 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 11 mg/dL\n 101 mEq/L\n 138 mEq/L\n 29.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n WBC\n 13.6\n 15.2\n 16.1\n Hct\n 28.5\n 28.1\n 29.3\n Plt\n 633\n 603\n 589\n Cr\n 0.5\n 0.7\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n Other labs: PT / PTT / INR:23.1/150.0/2.2, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:75.0 %, Band:0.0 %, Lymph:6.0 %, Mono:13.0 %,\n Eos:4.0 %, Albumin:2.6 g/dL, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 1. Diffuse parenchymal lung disease:\n -complete tx for PNA\n -start solumedrol 60 mg IV daily for possible inflammatory disease\n given we will not persue bronch or bx\n -IgE level\n -f/ /ANCA/antiGBM\n 2. DVT:\n -heparin gtt\n 3. Sacral decub:\n -on abx\n -cont. IV pain regimen\n 4. Pain/anxiety:\n -cont. IV opiates and benzos\n -geripsyche recs\n 5. FEN: refusing pos for now, consider IV nutrition\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined this pt, and was present with the ICU team for the\n key portions of services provided. 62 yo male with transverse myelitis,\n Sampter\ns triad, recent leg fracture, frequent UTI\ns admitted with\n shortness of breath and diffuse lung parenchymal infiltrates. On\n extensive abx (Vanc/zosyn/levaquin) for presumed aspiration but\n continues to be in acute respiratory distress on NRB for oxygenation.\n Some component of anxiety. Unable to proceed with more invasive testing\n (bronchoscopy) with pt DNR/DNI. Most of his w/u is pending, though CRP\n and ESR are very elevated.\n Continuing abx, adjusting sedation and pain medicines for pt comfort.\n With concerns for inflammatory lung disease and non-resolving\n respiratory distress, have discussed with his wife a trial of steroids\n while we wait for the rest of his w/u results to return.\n Pt is critically ill. Total time spent: 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:26 ------\n" }, { "category": "Physician ", "chartdate": "2164-02-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369964, "text": "TITLE:\n Chief Complaint: shortness of breath\n 24 Hour Events:\n - recs: Remeron solutab 15mg PO qHS\n - Met with PCP : start Haldol\n - Nutrition plan: wife OK with TPN if needed, no PEG, no NGT\n - Vanco trough 21 at 3 AM and dosed at 8 & 8, gave Vanco 750 x 1,\n trough at 7 AM\n - Watch creatinine, slowly trending up\n - ANCA, , UPEP: neg\n - SPEP, IGE, ACE, anti-GBM: P\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Levofloxacin - 08:10 AM\n Vancomycin - 10:11 PM\n Piperacillin/Tazobactam (Zosyn) - 12:28 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Lorazepam (Ativan) - 01:27 AM\n Fentanyl - 05:47 AM\n Haloperidol (Haldol) - 06:48 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Genitourinary: Foley\n Heme / Lymph: Anemia, Coagulopathy\n Psychiatric / Sleep: Agitated\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 100 (93 - 111) bpm\n BP: 131/78(89) {106/58(73) - 144/86(94)} mmHg\n RR: 28 (17 - 35) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,145 mL\n 787 mL\n PO:\n TF:\n IVF:\n 3,145 mL\n 787 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,720 mL\n 297 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed, ulceration\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 561 K/uL\n 10.6 g/dL\n 154 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.4 mEq/L\n 14 mg/dL\n 99 mEq/L\n 137 mEq/L\n 33.5 %\n 18.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n Plt\n 633\n 603\n 589\n 561\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n Other labs: PT / PTT / INR:24.2/71.3/2.4, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369966, "text": "TITLE:\n Chief Complaint: shortness of breath\n 24 Hour Events:\n - recs: Remeron solutab 15mg PO qHS\n - Met with PCP : start Haldol\n - Nutrition plan: wife OK with TPN if needed, no PEG, no NGT\n - Vanco trough 21 at 3 AM and dosed at 8 & 8, gave Vanco 750 x 1,\n trough 7 AM\n - Watch creatinine, slowly trending up\n - ANCA, , UPEP: neg\n - SPEP, IGE, ACE, anti-GBM: P\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Levofloxacin - 08:10 AM\n Vancomycin - 10:11 PM\n Piperacillin/Tazobactam (Zosyn) - 12:28 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Lorazepam (Ativan) - 01:27 AM\n Fentanyl - 05:47 AM\n Haloperidol (Haldol) - 06:48 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Genitourinary: Foley\n Heme / Lymph: Anemia, Coagulopathy\n Psychiatric / Sleep: Agitated\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 100 (93 - 111) bpm\n BP: 131/78(89) {106/58(73) - 144/86(94)} mmHg\n RR: 28 (17 - 35) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,145 mL\n 787 mL\n PO:\n TF:\n IVF:\n 3,145 mL\n 787 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n Drains:\n Balance:\n 1,720 mL\n 297 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed, ulceration\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 561 K/uL\n 10.6 g/dL\n 154 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.4 mEq/L\n 14 mg/dL\n 99 mEq/L\n 137 mEq/L\n 33.5 %\n 18.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n Plt\n 633\n 603\n 589\n 561\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n Other labs: PT / PTT / INR:24.2/71.3/2.4, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx (not currently producing sputum)\n - consider elective intubation for bronch but given pt adamantly DNI\n given possible need for trach, no bronch; also bronch would be\n difficult given desaturations\n - steroids (Solumedrol 60mg IV QD)\n - some coughing over last 24H, try to obtain sputum sample\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - run even\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n - palliative care consult\n - -psych c/s\n - prn fentanyl\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ NGT for TFs (if\n amenable)\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 07:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2164-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370085, "text": "Pt discharged home to Homecare and to have Hospice consult\n once at home. Emotional support given to wife throughout day in\n regards to discharging home, higher doses of oxygen therapy, pain\n management, skin care and wound management. Wife and patients\n questions and needs met throughout shift.\n" }, { "category": "Rehab Services", "chartdate": "2164-02-20 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 369875, "text": "Subjective:\nll try\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: CXR - The bibasilar consolidative changes\n of both lung bases, which are superimposed on underlying interstitial\n lung disease, appear relatively unchanged. New foci of atelectasis\n within the right line\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 104\n 129/58\n 97% on NRB\n Activity\n Sit\n 110\n 129/76\n 100% on NRB\n Recovery\n /\n Total distance walked:\n Minutes:\n Gait: not assessed\n Balance: mod A to maintain static sitting at edge of bed x 5 minutes,\n limited by anxiety\n Education / Communication: Reviewed deep breathing and encouraged\n position changes, patient's brother present and providing\n encouragement. Communicated with nsg re: status\n Other: CPT: gentle percussion/shaking to B lung fields in side-lying.\n Occasional weak cough, non-productive. Course breath sounds L>R\n Multiple wounds on buttocks with dressings intact\n Patient very limited by significant anxirty t/o tx.\n Assessment: 62 yo M with transverse myelitis making good progress in PT\n in that he is able to tolerate sitting at the edge of the bed as well\n as participcation in chest PT. He is significantly limited by anxiety\n and is well below his baseline functional mobility. Would continue to\n recommend rehab upon d/c to progress as able.\n Anticipated Discharge: Rehab\n Plan: continue with POC\n" }, { "category": "Nutrition", "chartdate": "2164-02-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 370068, "text": "Subjective\n Pt refusing pos\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 78.8 kg\n 24.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 77 kg adjusted d/t paraplegia\n 102%\n Diagnosis: pna\n PMH : TRANSVERSE MYELITIS: virus in 90s.\n CHRONIC PAIN\n CHRONIC UTI\n NEUROGENIC BLADDER\n DEPRESSION\n ASTHMA\n CONSTIPATION\n NASAL POLYPS\n BURSITIS - R HIP\n DECUBITUS ULCER\n SYNDROME\n Food allergies and intolerances: milk\n Pertinent medications: heparin, D5 1/2 NS @ 75 ml/hr, RISS,IV abx,\n protonix, methylprednisone, others noted\n Labs:\n Value\n Date\n Glucose\n 181 mg/dL\n 05:43 AM\n Glucose Finger Stick\n 224\n 06:00 AM\n BUN\n 21 mg/dL\n 05:43 AM\n Creatinine\n 1.1 mg/dL\n 05:43 AM\n Sodium\n 140 mEq/L\n 05:43 AM\n Potassium\n 3.5 mEq/L\n 05:43 AM\n Chloride\n 98 mEq/L\n 05:43 AM\n TCO2\n 31 mEq/L\n 05:43 AM\n pH (urine)\n 5.0 units\n 04:21 PM\n Albumin\n 2.6 g/dL\n 05:09 AM\n Calcium non-ionized\n 8.8 mg/dL\n 05:43 AM\n Phosphorus\n 4.6 mg/dL\n 05:43 AM\n Magnesium\n 2.4 mg/dL\n 05:43 AM\n ALT\n 27 IU/L\n 05:09 AM\n Alkaline Phosphate\n 157 IU/L\n 05:09 AM\n AST\n 39 IU/L\n 05:09 AM\n Total Bilirubin\n 0.3 mg/dL\n 05:09 AM\n WBC\n 16.5 K/uL\n 05:43 AM\n Hgb\n 10.2 g/dL\n 05:43 AM\n Hematocrit\n 33.3 %\n 05:43 AM\n Current diet order / nutrition support: soft, thin liquids\n PPN Order: 1.5 L 75 g dextrose/ 52.5 g Amino Acids/ lipids 20% in 250\n ml\n GI: soft, hypoactive bowel sounds\n Skin:stage IV left gluteal/ischial, Stage III sacrum, Stage II right\n ischial\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake, NPO / hypocaloric diet, multiple\n pressure ulcers\n Estimated Nutritional Needs based on admit wt\n Calories: -2310 ( 25-30 cal/kg)\n Protein: 92-116 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics: 62 year old male admitted after 2 days of SOB.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n At risk for refeeding syndrome (monitor K / PO4 / Magnesium and repeat\n as needed):\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Change to non-dextrose IV fluids\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2164-02-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 370070, "text": "Subjective\n Pt refusing pos\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 78.8 kg\n 24.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 77 kg adjusted d/t paraplegia\n 102%\n Diagnosis: pna\n PMH : TRANSVERSE MYELITIS: virus in 90s.\n CHRONIC PAIN\n CHRONIC UTI\n NEUROGENIC BLADDER\n DEPRESSION\n ASTHMA\n CONSTIPATION\n NASAL POLYPS\n BURSITIS - R HIP\n DECUBITUS ULCER\n SYNDROME\n Food allergies and intolerances: milk\n Pertinent medications: heparin, D5 1/2 NS @ 75 ml/hr, RISS,IV abx,\n protonix, methylprednisone, others noted\n Labs:\n Value\n Date\n Glucose\n 181 mg/dL\n 05:43 AM\n Glucose Finger Stick\n 224\n 06:00 AM\n BUN\n 21 mg/dL\n 05:43 AM\n Creatinine\n 1.1 mg/dL\n 05:43 AM\n Sodium\n 140 mEq/L\n 05:43 AM\n Potassium\n 3.5 mEq/L\n 05:43 AM\n Chloride\n 98 mEq/L\n 05:43 AM\n TCO2\n 31 mEq/L\n 05:43 AM\n pH (urine)\n 5.0 units\n 04:21 PM\n Albumin\n 2.6 g/dL\n 05:09 AM\n Calcium non-ionized\n 8.8 mg/dL\n 05:43 AM\n Phosphorus\n 4.6 mg/dL\n 05:43 AM\n Magnesium\n 2.4 mg/dL\n 05:43 AM\n ALT\n 27 IU/L\n 05:09 AM\n Alkaline Phosphate\n 157 IU/L\n 05:09 AM\n AST\n 39 IU/L\n 05:09 AM\n Total Bilirubin\n 0.3 mg/dL\n 05:09 AM\n WBC\n 16.5 K/uL\n 05:43 AM\n Hgb\n 10.2 g/dL\n 05:43 AM\n Hematocrit\n 33.3 %\n 05:43 AM\n Current diet order / nutrition support: soft, thin liquids\n Order: 1.5 L 75 g dextrose/ 52.5 g Amino Acids/ lipids 20% in 250\n ml (515 kcals/ 52 g protein)\n GI: soft, hypoactive bowel sounds\n Skin:stage IV left gluteal/ischial, Stage III sacrum, Stage II right\n ischial\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake, NPO / hypocaloric diet, multiple\n pressure ulcers\n Estimated Nutritional Needs based on admit wt\n Calories: -2310 ( 25-30 cal/kg)\n Protein: 92-116 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics: 62 year old male with history of transverse myelitis\n complicated by paraplegia who presents with two days of shortness of\n breath. The patient has had a complicated recent history involving a\n tib/fib fx sustained while moving in his wheel chair. Pt seen by SLP on\n who recommended NPO d/t respiratory status, however pt is refusing\n to take pos including pills. Received consult for TPN recs. Pt\ns family\n does not want PEG and NGT is not an option d/t previous septal work. Pt\n currently receiving , need central access for TPN. TPN recs\n below. Noted possible plan for d/c home with hospice.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n At risk for refeeding syndrome (monitor K / PO4 / Magnesium and repeat\n as needed):\n TPN recommendations\n Once central access is obtained start with Day starter\n TPN\n Pending glycemic control advance to goal TPN 2.1L( 310 g\n Dextrose/ 115g amino acids/ 45 g fat) = kcals\n Check TG hold lipids if >400\n Check chemistry 10 panel daily and adjust lytes per am labs\n Change to non-dextrose IV fluids\n Will follow plan of care page with questions\n" }, { "category": "Physician ", "chartdate": "2164-02-22 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370077, "text": "Chief Complaint: dyspnea\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o M w/transverse myelitis, adm with dyspnea and ILD of unclear\n etiology.\n 24 Hour Events:\n - weaned down to 2L NC while sleeping and did well, but then woke up\n and became anxious, requested NRB.\n - refusing all po meds\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Vancomycin - 07:55 AM\n Piperacillin/Tazobactam (Zosyn) - 09:04 AM\n Levofloxacin - 09:54 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Fentanyl - 03:00 PM\n Lorazepam (Ativan) - 12:06 AM\n Haloperidol (Haldol) - 12:06 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n insulin sliding scale, zosyn, levaquin, heparin gtt, fentanyl patch,\n synthroid, protonix, solumedrol 60 iv daily, vanc, ativan 1-2 mg IV q4h\n prn, haldol 2 mg\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 84 (84 - 112) bpm\n BP: 136/80(93) {117/65(78) - 149/97(106)} mmHg\n RR: 13 (13 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,740 mL\n 2,447 mL\n PO:\n TF:\n IVF:\n 2,563 mL\n 1,526 mL\n Blood products:\n Total out:\n 1,490 mL\n 1,620 mL\n Urine:\n 1,490 mL\n 1,620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,250 mL\n 827 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n way up bilaterally, Bronchial: at L base)\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.2 g/dL\n 588 K/uL\n 181 mg/dL\n 1.1 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 98 mEq/L\n 140 mEq/L\n 33.3 %\n 16.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n 05:43 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n 16.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n 33.3\n Plt\n 633\n 603\n 589\n 561\n 588\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n 1.2\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n 110\n 181\n Other labs: PT / PTT / INR:17.7/74.6/1.6, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Imaging: CXR unchanged.\n Microbiology: No new micro data.\n Assessment and Plan\n 62 y/o M w/transverse myelitis, adm with ILD, now being empirically\n treated with steroids. Psych issues currently predominating.\n # Hypoxemia: Unclear cause of ILD. Being empirically treated with\n steroids and antibiotics. Will d/c zosyn and decrease levoflox dose to\n 500 mg daily. Cont current dose of solumedrol. Multiple serologies\n pending.\n # Decubitus ulcers: Stage IV. Cont empiric vanc for now.\n # : Felt due to volume depletion. Check urine eos.\n # DVT: Cont heparin gtt.\n # Tib-fib Fracture: Cont boot.\n Major issue remains disposition and psych issues. Will need to discuss\n with pt and family whether he wants to go home with hospice vs\n continuing medical management. Continue ativan and haldol for now.\n ICU Care\n Nutrition:\n Peripheral Parenteral Nutrition - 09:10 PM 62.5 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 09:20 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n ------ Protected Section ------\n I saw and examined the pt, and was present with the ICU team for the\n key portions of the services provided. Pt calmer over the past day with\n regular dosing of haldol and ativan; oxygen requirement down to 2\n liters n.c. while sleeping. A meeting was held with the pt and wife\n today with goals of transitioning home and conversion of all meds to\n oral as he will not be going home with an indwelling IV. They are\n interested in ensuring that ancillary support is established prior to\n discharge, and appeared amenable to our getting hospice services\n involved. They would like this set-up before he goes home, anticipating\n discharge today or tomorrow.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:45 PM ------\n" }, { "category": "Nursing", "chartdate": "2164-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369765, "text": "Hypoxemia\n Assessment:\n Pt on humidified aerosol mask 50%, lungs CTA upper lobes, diminished at\n bases with periods of desat, ? related to anxiety\n Action:\n Pt placed on non-rebreather, 0.125 mg xanax given\n Response:\n O2 sats > 98% on non-rebreather and s/p xanax\n Plan:\n Continue to monitor respiratory status, monitor VS\n .H/O anxiety\n Assessment:\n pt calling out\ngive me xanax, give me xanax. You \n me to get\n upset\n. O2 sats mid 80s on humidified aerosol mask\n Action:\n 0.125 mg xanax given as ordered\n Response:\n Pt sleeping comfortably, O2 sats > 94%\n Plan:\n Continue to monitor for anxiety, educate pt re: alternate ways to\n relieve anxiety, administer xanax as needed\n Pt on 2100 units heparin/hr, PTT at 23:00 = 79.5, continued on 2100\n units per hour. Repeat PTT at 0600 pending.\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369958, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, started on\n halodol 2 mg IV as PRN basis. Geriatric consulted. Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LS rhonchorous bilaterally,\n diminished at bases; continues on vacno/zosyn/levaquin, no sputum\n culture as pt unable to produce. Patient refused neb treatments.\n Action:\n Nebs q6h as tolerates, remains on NRB, attempted to wean off, but\n patient becomes agitated and desats to 80\ns. Vanc level yesterday am\n was 21. Pt. dosed this evening with 750mg instead of 1gm. Will check\n trough in am prior to dosing.\n Response:\n Sating high 90\ns on NRB, RR 20-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings on right changed\n overnight, applied. Sacral changed overnight.\n Response:\n No changes\n Plan:\n Plastics and wound care following. Change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given. Also,\n given additional 0.5mg Ativan 1 time dose. Haldol 2 mg IV X1 given.\n Response:\n Pt very agitated, yelling out, denies pain, continues to refuse PO\n meds, MD aware. RR at 16-20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 74 at MN.\n Response:\n Heparin gtt therapeutic remains @ 1500 units /hr .\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 6am pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete.\n Action:\n Second liter D5\n NS at 75 cc/hr started . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds. K 5.4 at MN, IVF changed to D51/2NS\n at 75cc/hr.\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369758, "text": "Hypoxemia\n Assessment:\n Pt on humidified aerosol mask 50%, lungs CTA upper lobes, diminished at\n bases with periods of desat, ? related to anxiety\n Action:\n Pt placed on non-rebreather, 0.12 mg xanax given\n Response:\n O2 sats > 98% on non-rebreather\n Plan:\n Continue to monitor respiratory status, monitor VS\n .H/O anxiety\n Assessment:\n pt calling out\ngive me xanax, give me xanax. You \n me to get\n upset\n. O2 sats mid 80s on humidified aerosol mask\n Action:\n 0.125 mg xanax given as ordered\n Response:\n Pt sleeping comfortably, O2 sats > 94%\n Plan:\n Continue to monitor for anxiety, educate pt re: alternate ways to\n relieve anxiety, administer xanax as needed\n Pt on 2100 units heparin/hr, PTT at 23:00 = 79.5, continued on 2100\n units per hour.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369843, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n EVENTS: beginning of shift, pt requesting bedpan, family left room to\n waiting room, bedpan given, shortly afterwards, pt began yelling out,\n agitated, asking for\nshot\n, fentanyl given per prn orders, family\n called and returned to bedside, pt extremely agitated, then asking for\nshot for panic\n, given ativan IVP, took approx\n hour for pt to\n recover from episode, during that time he was tachypneic to 30\n desatting to 80\ns, very anxious; pt settled; patient\ns wife requesting\n for assistance getting bedpan out from under pt; 2 RN\ns turning pt, as\n pt\ns wife yelling at staff for being too rough, wife picked up bedpan\n and threw it at this RN, then began yelling at another RN, grabbing\n RN\ns arm and pulling her across the bed, escalating and screaming in\n her face, wife then walked out of room, this RN attempting to calm\n wife, wife and pt\ns brother left unit; wife returned, behavior\n appropriate, wife apologized to staff, Clinical Supervisor notified and\n spoke with family members, no further issues with family tonight\n Today, PCP to come in and discuss hospice care with pt and family;\n overnight, pt refusing all PO\ns except ice chips\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting 100% currently, RR teens, regular, appears comfortable, LS now\n with RUL rhonchi\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax;\n tonight pt had episode where he became agitated and anxious, requesting\n a\nshot for panic\n , yelling out, unable to calm pt, desatting to 80\n RR to 30\n Action:\n Pt family called to be at patient\ns bedside, given prn fentanyl and one\n time order of ativan; attemped to administer patient\ns standing xanax\n and methadone throughout shift but pt refusing\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse xanax, also unable to give all other PO meds, MD\n aware\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @ 2100 units/hr, +PP bilaterally,\n bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT therapeutic, 82.6\n Response:\n PTT @ 4a >150, gtt off x1h, resuming at 1900units/hr\n Plan:\n Q6h PTT, gtt therapeutic, goal 60-100\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, started D5\n @ 100cc/hr x 500cc\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 100cc/hr x1L\n" }, { "category": "Nursing", "chartdate": "2164-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370048, "text": "Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns continues on vacno/zosyn/levaquin, no sputum\n culture as pt unable to produce. Patient refused nebs\n Action:\n Nebs q6h, remains on NRB, placed pt on NC 3L, but pt desat to 89. vanc\n not given.\n Response:\n Satting high 90\ns., RR 10-30\ns. cont NRB.\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n given. Ativan IV q 4 hourly given. Hallodol 2 mg IV given. See\n metavision for details.\n Response:\n Pt calm and sleeping. Morning dose of Ativan held. Denies pain,\n continues to refuse PO meds, MD aware. RR at30-40\ns when agitated. At\n rest RR at 20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1300 hrs : 72.7 , 3 PTT\ns been in goal range\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n PTT goal 60-100.possible change to Lovenox\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home . cont d5%1/2 NS at 75 cc/hr\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.start PPN nad given lipids 20%\n over 6hr\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Physician ", "chartdate": "2164-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370058, "text": "TITLE:\n Chief Complaint: Difficulty breathing\n 24 Hour Events:\n - CXR: Interval worsening\n - Goal to wean FiO2 if possible, not attained\n - Discontinued all oral medications patient is repeatedly refusing\n including: Clonazepam 0.5 mg PO QID, Docusate Sodium 800 mg PO BID,\n Uroqid-Acid No.2 *NF* 500-500 mg Oral , Lactulose 30 mL PO TID,\n Pseudoephedrine 30 mg PO Q6H:PRN, Neo-Synephrine *NF* 0.5 % NU qid:prn,\n Sodium Chloride Nasal SPRY NU QID:PRN, Baclofen 30 mg PO BID,\n Mucinex *NF* 600 mg Oral , Zinc Sulfate 220 mg PO DAILY,\n Theophylline SR 600 mg PO DAILY, Ascorbic Acid 1000 mg PO BID,\n Polyethylene Glycol 17 g PO DAILY, Simethicone 40-80 mg PO QID:PRN,\n Multivitamins 1 TAB PO DAILY, Guaifenesin mL PO Q6H:PRN,\n Fexofenadine 60 mg PO BID, Methadone 20 mg PO BID, Ondansetron 4 mg IV\n Q8H:PRN, Calcium Carbonate 500 mg PO QID:PRN, Acetaminophen 325-650 mg\n PO Q6H:PRN, Montelukast Sodium 10 mg PO DAILY, Mexiletine 150 mg PO\n Q12H, Fentanyl Citrate *NF* 800 mcg Buccal QID pain, BuPROPion\n (Sustained Release) 100 mg PO BID\n - Seen by PCP, . , states patient should go home\n - - if unwilling to have g-tube, then should address goals of care\n and comfort measures\n - Given peripheral TPN and lipids\n - Psych - concerned about abrupt cessation of benzos and opiates.\n recommend haldol 2mg iv bid plus 1 mg q2hrs prn. would continue to\n give ativan .5-1mg q6h prn; recommend continuation of po benzos and\n wellbutrim if pt goes home (and not on hospice)\n - FeNa 1.2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Vancomycin - 10:11 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:13 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Fentanyl - 03:00 PM\n Lorazepam (Ativan) - 12:06 AM\n Haloperidol (Haldol) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Cardiovascular: Edema\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: LE b/l\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 97 (92 - 112) bpm\n BP: 141/77(92) {117/65(78) - 149/97(106)} mmHg\n RR: 22 (15 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,740 mL\n 1,522 mL\n PO:\n TF:\n IVF:\n 2,563 mL\n 792 mL\n Blood products:\n Total out:\n 1,490 mL\n 1,220 mL\n Urine:\n 1,490 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,250 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///31/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, sacral decubitus ulcers\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Decreased\n Labs / Radiology\n 588 K/uL\n 10.2 g/dL\n 181 mg/dL\n 1.1 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 98 mEq/L\n 140 mEq/L\n 33.3 %\n 16.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n 05:43 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n 16.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n 33.3\n Plt\n 633\n 603\n 589\n 561\n 588\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n 1.2\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n 110\n 181\n Other labs: PT / PTT / INR:17.7/74.6/1.6, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n ICU Care\n Nutrition:\n Peripheral Parenteral Nutrition - 09:10 PM 62.5 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 09:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370059, "text": "TITLE:\n Chief Complaint: Difficulty breathing\n 24 Hour Events:\n - CXR: Interval worsening\n - Goal to wean FiO2 if possible, not attained\n - Discontinued all oral medications patient is repeatedly refusing\n including: Clonazepam 0.5 mg PO QID, Docusate Sodium 800 mg PO BID,\n Uroqid-Acid No.2 *NF* 500-500 mg Oral , Lactulose 30 mL PO TID,\n Pseudoephedrine 30 mg PO Q6H:PRN, Neo-Synephrine *NF* 0.5 % NU qid:prn,\n Sodium Chloride Nasal SPRY NU QID:PRN, Baclofen 30 mg PO BID,\n Mucinex *NF* 600 mg Oral , Zinc Sulfate 220 mg PO DAILY,\n Theophylline SR 600 mg PO DAILY, Ascorbic Acid 1000 mg PO BID,\n Polyethylene Glycol 17 g PO DAILY, Simethicone 40-80 mg PO QID:PRN,\n Multivitamins 1 TAB PO DAILY, Guaifenesin mL PO Q6H:PRN,\n Fexofenadine 60 mg PO BID, Methadone 20 mg PO BID, Ondansetron 4 mg IV\n Q8H:PRN, Calcium Carbonate 500 mg PO QID:PRN, Acetaminophen 325-650 mg\n PO Q6H:PRN, Montelukast Sodium 10 mg PO DAILY, Mexiletine 150 mg PO\n Q12H, Fentanyl Citrate *NF* 800 mcg Buccal QID pain, BuPROPion\n (Sustained Release) 100 mg PO BID\n - Seen by PCP, . , states patient should go home\n - - if unwilling to have g-tube, then should address goals of care\n and comfort measures\n - Given peripheral TPN and lipids\n - Psych - concerned about abrupt cessation of benzos and opiates.\n recommend haldol 2mg iv bid plus 1 mg q2hrs prn. would continue to\n give ativan .5-1mg q6h prn; recommend continuation of po benzos and\n wellbutrim if pt goes home (and not on hospice)\n - FeNa 1.2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Vancomycin - 10:11 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:13 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Fentanyl - 03:00 PM\n Lorazepam (Ativan) - 12:06 AM\n Haloperidol (Haldol) - 12:06 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Cardiovascular: Edema\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: LE b/l\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 97 (92 - 112) bpm\n BP: 141/77(92) {117/65(78) - 149/97(106)} mmHg\n RR: 22 (15 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,740 mL\n 1,522 mL\n PO:\n TF:\n IVF:\n 2,563 mL\n 792 mL\n Blood products:\n Total out:\n 1,490 mL\n 1,220 mL\n Urine:\n 1,490 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,250 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///31/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, sacral decubitus ulcers\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Decreased\n Labs / Radiology\n 588 K/uL\n 10.2 g/dL\n 181 mg/dL\n 1.1 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 98 mEq/L\n 140 mEq/L\n 33.3 %\n 16.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n 05:43 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n 16.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n 33.3\n Plt\n 633\n 603\n 589\n 561\n 588\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n 1.2\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n 110\n 181\n Other labs: PT / PTT / INR:17.7/74.6/1.6, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx. Did consider elective\n intubation for bronch but given pt adamantly DNI given possible need\n for trach, no bronch; also bronch would be difficult given\n desaturations\n - continue vanco, pip-tazo, levoflox for now\n - steroids (Solumedrol 60mg IV QD)\n - some coughing over last 24H, try to obtain sputum sample\n - CXR this AM\n - Follow-up ACE-I, IGE, anti-GBM\n # ARF: Worsening since admission, unclear etiology. UA negative for\n infection. FeNa = 1.2. Likely some component of prerenal despite\n this given poor po intake.\n - Maintenance fluid while NPO\n - Send urine eos given new antibiotics\n - Trend, renally dose meds\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - encourage improved nutition as likely reflects prealbumin = 2\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n - holding vitamins / zinc currently as patient refusing all oral\n medications\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically. Ortho aware.\n - Continue boot\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fentanyl.\n - Continue meds cautiously given resp status\n - palliative care consult:\n - -psych c/s: start remeron\n - prn fentanyl\n - continue IV ativan, IV haldol, IV fentanyl\n - psyche consult\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ minimal PO, consider\n continued peripheral nutrition\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: Wife\n .\n # DISPO: ICU for now vs home with hospice\n ICU Care\n Nutrition:\n Peripheral Parenteral Nutrition - 09:10 PM 62.5 mL/hour\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 09:20 PM\n" }, { "category": "Physician ", "chartdate": "2164-02-22 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 370064, "text": "Chief Complaint: dyspnea\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o M w/transverse myelitis, adm with dyspnea and ILD of unclear\n etiology.\n 24 Hour Events:\n - weaned down to 2L NC while sleeping and did well, but then woke up\n and became anxious, requested NRB.\n - refusing all po meds\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Vancomycin - 07:55 AM\n Piperacillin/Tazobactam (Zosyn) - 09:04 AM\n Levofloxacin - 09:54 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Fentanyl - 03:00 PM\n Lorazepam (Ativan) - 12:06 AM\n Haloperidol (Haldol) - 12:06 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n insulin sliding scale, zosyn, levaquin, heparin gtt, fentanyl patch,\n synthroid, protonix, solumedrol 60 iv daily, vanc, ativan 1-2 mg IV q4h\n prn, haldol 2 mg\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 84 (84 - 112) bpm\n BP: 136/80(93) {117/65(78) - 149/97(106)} mmHg\n RR: 13 (13 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,740 mL\n 2,447 mL\n PO:\n TF:\n IVF:\n 2,563 mL\n 1,526 mL\n Blood products:\n Total out:\n 1,490 mL\n 1,620 mL\n Urine:\n 1,490 mL\n 1,620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,250 mL\n 827 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n way up bilaterally, Bronchial: at L base)\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.2 g/dL\n 588 K/uL\n 181 mg/dL\n 1.1 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 98 mEq/L\n 140 mEq/L\n 33.3 %\n 16.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n 05:43 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n 16.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n 33.3\n Plt\n 633\n 603\n 589\n 561\n 588\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n 1.2\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n 110\n 181\n Other labs: PT / PTT / INR:17.7/74.6/1.6, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Imaging: CXR unchanged.\n Microbiology: No new micro data.\n Assessment and Plan\n 62 y/o M w/transverse myelitis, adm with ILD, now being empirically\n treated with steroids. Psych issues currently predominating.\n # Hypoxemia: Unclear cause of ILD. Being empirically treated with\n steroids and antibiotics. Will d/c zosyn and decrease levoflox dose to\n 500 mg daily. Cont current dose of solumedrol. Multiple serologies\n pending.\n # Decubitus ulcers: Stage IV. Cont empiric vanc for now.\n # : Felt due to volume depletion. Check urine eos.\n # DVT: Cont heparin gtt.\n # Tib-fib Fracture: Cont boot.\n Major issue remains disposition and psych issues. Will need to discuss\n with pt and family whether he wants to go home with hospice vs\n continuing medical management. Continue ativan and haldol for now.\n ICU Care\n Nutrition:\n Peripheral Parenteral Nutrition - 09:10 PM 62.5 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 09:20 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2164-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 370066, "text": "TITLE:\n Chief Complaint: Difficulty breathing\n 24 Hour Events:\n - CXR: Interval worsening\n - Goal to wean FiO2 if possible, not attained\n - Discontinued all oral medications patient is repeatedly refusing\n including: Clonazepam 0.5 mg PO QID, Docusate Sodium 800 mg PO BID,\n Uroqid-Acid No.2 *NF* 500-500 mg Oral , Lactulose 30 mL PO TID,\n Pseudoephedrine 30 mg PO Q6H:PRN, Neo-Synephrine *NF* 0.5 % NU qid:prn,\n Sodium Chloride Nasal SPRY NU QID:PRN, Baclofen 30 mg PO BID,\n Mucinex *NF* 600 mg Oral , Zinc Sulfate 220 mg PO DAILY,\n Theophylline SR 600 mg PO DAILY, Ascorbic Acid 1000 mg PO BID,\n Polyethylene Glycol 17 g PO DAILY, Simethicone 40-80 mg PO QID:PRN,\n Multivitamins 1 TAB PO DAILY, Guaifenesin mL PO Q6H:PRN,\n Fexofenadine 60 mg PO BID, Methadone 20 mg PO BID, Ondansetron 4 mg IV\n Q8H:PRN, Calcium Carbonate 500 mg PO QID:PRN, Acetaminophen 325-650 mg\n PO Q6H:PRN, Montelukast Sodium 10 mg PO DAILY, Mexiletine 150 mg PO\n Q12H, Fentanyl Citrate *NF* 800 mcg Buccal QID pain, BuPROPion\n (Sustained Release) 100 mg PO BID\n - Seen by PCP, . , states patient should go home\n - - if unwilling to have g-tube, then should address goals of care\n and comfort measures\n - Given peripheral TPN and lipids\n - Psych - concerned about abrupt cessation of benzos and opiates.\n recommend haldol 2mg iv bid plus 1 mg q2hrs prn. would continue to\n give ativan .5-1mg q6h prn; recommend continuation of po benzos and\n wellbutrim if pt goes home (and not on hospice)\n - FeNa 1.2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsAspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin - 04:16 PM\n Vancomycin - 10:11 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 12:13 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Fentanyl - 03:00 PM\n Lorazepam (Ativan) - 12:06 AM\n Haloperidol (Haldol) - 12:06 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Cardiovascular: Edema\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Agitated\n Pain: Moderate\n Pain location: LE b/l\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.2\nC (95.4\n HR: 97 (92 - 112) bpm\n BP: 141/77(92) {117/65(78) - 149/97(106)} mmHg\n RR: 22 (15 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,740 mL\n 1,522 mL\n PO:\n TF:\n IVF:\n 2,563 mL\n 792 mL\n Blood products:\n Total out:\n 1,490 mL\n 1,220 mL\n Urine:\n 1,490 mL\n 1,220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,250 mL\n 302 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///31/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, sacral decubitus ulcers\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Decreased\n Labs / Radiology\n 588 K/uL\n 10.2 g/dL\n 181 mg/dL\n 1.1 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 98 mEq/L\n 140 mEq/L\n 33.3 %\n 16.5 K/uL\n [image002.jpg]\n 05:09 AM\n 04:06 AM\n 03:13 AM\n 11:48 PM\n 05:57 AM\n 05:43 AM\n WBC\n 13.6\n 15.2\n 16.1\n 18.5\n 16.5\n Hct\n 28.5\n 28.1\n 29.3\n 33.5\n 33.3\n Plt\n 633\n 603\n 589\n 561\n 588\n Cr\n 0.5\n 0.7\n 1.1\n 1.3\n 1.2\n 1.1\n TropT\n 0.02\n Glucose\n 104\n 161\n 154\n 154\n 110\n 181\n Other labs: PT / PTT / INR:17.7/74.6/1.6, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:91.3 %, Band:0.0 %, Lymph:5.8 %, Mono:2.8 %, Eos:0.1\n %, Albumin:2.6 g/dL, Ca++:8.8 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n ANXIETY\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, CHRONIC\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx. Did consider elective\n intubation for bronch but given pt adamantly DNI given possible need\n for trach, no bronch; also bronch would be difficult given\n desaturations\n - continue vanco, pip-tazo, levoflox for now\n - steroids (Solumedrol 60mg IV QD)\n will need po equivalent if going\n home\n - some coughing over last 24H, try to obtain sputum sample\n - Follow-up ACE-I, IGE, anti-GBM\n # ARF: Worsening since admission, unclear etiology. UA negative for\n infection. FeNa = 1.2. Likely some component of prerenal despite\n this given poor po intake.\n - Maintenance fluid while NPO\n - Send urine eos given new antibiotics\n - Trend, renally dose meds\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now, will not go home on anti-coagulation\n - encourage improved nutition as likely reflects prealbumin = 2\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs & on Vancomycin\n - f/u plastics consult\n - holding vitamins / zinc currently as patient refusing all oral\n medications\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically. Ortho aware.\n - Continue boot\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fentanyl.\n - Continue meds cautiously given resp status\n - palliative care consult recs\n - -psych c/s: start remeron\n - prn fentanyl\n - continue IV ativan, IV haldol, IV fentanyl\n - psyche consult recs\n .\n # FEN: IVFs / replete lytes prn / bowel regimen/ minimal PO, consider\n continued peripheral nutrition\n .\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: DNR/DNI\n # CONTACT: Wife\n .\n # DISPO: ICU for now vs home with hospice, family mtg today\n ICU Care\n Nutrition:\n Peripheral Parenteral Nutrition - 09:10 PM 62.5 mL/hour\n Lines:\n 18 Gauge - 01:22 PM\n 20 Gauge - 09:20 PM\n" }, { "category": "Nutrition", "chartdate": "2164-02-15 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 369496, "text": "Ht: 70\n Wt: 78.8kg\n 102% IBW (adjusted for paraplegia) / BMI = 24.9\n Diet: NPO\n Meds: Vit C, Zinc, MVI, Lactulose/Colace; others noted\n Allergies/intolerance: Milk\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 62 y/o male presents w/ 2 days of SOB. CTA (-) for PE. Pt triggered\n on floor and transferred to MICU for further management. Received RN\n email consult for stage III\n IV decubitis ulcer. Wound RN consult\n pending. Per pt, eats all food pureed at home. Avoids milk products,\n drinks rice milk. Does not like Ensure/Boost shakes because they give\n him gas. c/o chronic constipation. Reports stable weight and fair\n appetite PTA. Pt seen by SLP this AM who recommended soft solids and\n thin liquids. Po supplementation is indicated, however pt does not like\n Ensure shakes (although they are lactose free).\n RECS:\n 1. Advance diet to soft solids and thin liquids\n 2. Encourage/assist w/ po\n 3. Will send Resource Breeze \n 4. Continue MVI, vit C, Zinc; if decubitis ulcer found to be\n stage III-IV, recommend add Vit A 250,000 IU x 10 days\n 5. Will follow up to check po\ns; page if ?s *\n 6. Electronically signed by , RD, LDN\n 11:54\n 7.\n 8.\n" }, { "category": "Physician ", "chartdate": "2164-02-15 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 369500, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o m w paraplegia, asthma p/w SOB and LE edema to ED yesterday. CTA\n done showed no PE, but bilat lower lobe GGO, concerning for aspiration\n or CHF. Given vanco and zosyn in ED. Sat 80% on NC. 7.49.44.141 on NRB.\n Given 20 mg IV lasix. Went initially to the floor, then sent here for\n concerning oxygen requirement.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Vancomycin - 03:37 AM\n Levofloxacin - 05:14 AM\n Infusions:\n Other ICU medications:\n Other medications:\n albuterol, alprazolam, baclofen, buproprion, zyrtec, clonazepam,\n fentanyl patch, lactulose, levothyroxine, mexilitine, singulair,\n omeprazole, miralax, theophylline\n Past medical history:\n Family history:\n Social History:\n Transverse myelitis c/b paraplegia\n Chronic Foley\n Sacral Decubs\n Tib/fib fx\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives with wife\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Flowsheet Data as of 09:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.4\nC (97.5\n HR: 97 (96 - 117) bpm\n BP: 102/58(69) {98/55(65) - 120/75(83)} mmHg\n RR: 15 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -540 mL\n Respiratory\n O2 Delivery Device: Venti mask\n FiO2: 0.35\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : bibasilar)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 633 K/uL\n 28.5 %\n 9.6 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 5 mg/dL\n 34 mEq/L\n 92 mEq/L\n 3.4 mEq/L\n 132 mEq/L\n 13.6 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 13.6\n Hct\n 28.5\n Plt\n 633\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 104\n Other labs: PT / PTT / INR:14.6/28.2/1.3, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n Plan:\n 1. Hypoxemia: Possible asp PNA vs. CAP vs. Inflammatory process vs. CHF\n -cont. gentle diuresis, although BNP 700\n -check sputum cx\n -concerning for inflammatory process as well, although seems to be\n improving\n -TTE\n -plan for repeat CT in a few days\n -vanco/zosyn/levaquin\n -swallow eval\n 2. Chronic pain: cont. methadone and fentanyl\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 18 Gauge - 02:37 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n I saw and examined this pt and was present with the ICU team for the\n key portions of services provided. 62 yo male with transverse myelitis\n and paraplegia, chronic indwelling Foley with frequent UTI\ns, Samter\n traid (aspirin sensitivity/asthma/nasal polyposis), sacral decub, hx of\n Pseudomonas PNA and recent right tib/fib fracture. Admitted with abrupt\n SOB/fevers, hypoxia and leukocytosis, then transferred from floor with\n worsening respiratory distress. Pt feels improved this morning with\n reduction in o2 to 35%, decreasing WBC with major interventions being\n antibiotics (zosyn/levaquin/vanc) and a small dose of lasix. CTA\n negative for PE, enormous trachea/bronchi, dilated esophagus,\n +bronchiectasis (also seen on , scans) diffuse gr/glass\n infiltrates but most prominent in lower lobes. LE dopplers + for L-DVT.\n Review of hospital records demonstrate 2 admissions for Pseudomonas PNA\n yrs ago, prior n\nl quan.immunoglobulins.\n Given fevers/leukocytosis with improvement on antbiotics, probably asp\n PNA- he doesn\nt recall overt aspiration but at increased risk with\n enlarged esophagus. On broad coverage abx with zosyn/levaquin/vanc. Not\n especially suspicious for volume overload but will obtain Echo to eval\n LV function. Appears appropriate for floor transfer.\n" }, { "category": "Nursing", "chartdate": "2164-02-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 369506, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. The\n patient has had a complicated recent history involving a tib/fib fx\n sustained while moving in his wheel chair. This was not treated\n surgically. He also has a sacral decub which was treated with 2 weeks\n of cipro then 2 weeks of levofloxacin. Over the past two days he has\n been having increasing shortness of breath. He has oxygen at home which\n he normally does not use. He has been using up to 4L 1 day PTA. He\n reports no fevers of chills. He has been taking his temp and no\n documented fevers. He does not endorse ant chest pain. His wife notes\n that although his right leg is constantly swollen from the fracture,\n his left leg has been having increasing swelling over the past few\n days. His wife also notes that he has been increasingly lethargic over\n the past few days as well.\n .\n In the ED, he recieved Vanc and Zosyn. CTA neg for PE but showed no\n central PE but bibasal GGO and more consolidative opc w/enlarged\n subcarinal ? pna (preliminary read). The Medicine housetaff\n discussed scan with Pulmonary, who felt this scan likely represented\n aspiration, or CHF, less likely ILD.\n .\n Upon arrival to the medicine floor his sats were in the 80s on NC and\n he required a NRB to attain sats in the 90s. An ABG was performed\n 7.49/44/141. He was given 20mg IV lasix. He was eventually able to be\n placed on a 40% venturi mask. His oral temp was 99.7. He was short of\n breath when not on the NRB. The patient is being transferred to the\n MICU for higher level of nursing care and closer monitoring given\n fluctuating oxygen requirement.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain,\n nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,\n dysuria, hematuria.\n Hypoxemia\n Assessment:\n Started shift on 35% humidified face mask, o2sat 100%\n Action:\n Placed on 4L nc while taking meds, placed back on 35% humidified face\n mask per pt request. ECHO for ? CHF and lower extremity US. Started on\n Hep gtt w/ 3000Unit bolus to start.\n Response:\n Tolerated 4L NC but preferred the humidified air. C/O dry throat and\n dry tissue build up in the back of his throat when too long on NC. (on\n and off NC @ home). ECHO results pending, LENI showed DVT.\n Plan:\n Cont to monitor resp status, nebs, Pulmonary consult to be ordered, ?\n bronch eventually and/or repeat chest CT for ? interstitial process.\n Next PTT for Hep gtt is 2000pm.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubiti on sacral area and buttocks and sm. Area on\n medial R knee from brace.\n Action:\n Wound care consult, incident report (chronic wounds from home),\n plastics consult, dsgs changed per wound care rec\ns, ordered first step\n bed w/ MRS \n Response:\n Plastics will follow and discuss a plan, ortho consult for tib/fib\n fracture (brace on R leg causing knee pressure ulcer), dsg\ns remain\n intact\n Plan:\n Plastics to determine plan for Stage 4 on R glute/ishial area (?\n Osteomyelitis now as well), change stage 4dsg QD and others PRN or\n Q3days if dsg\ns remain intact.\n Chronic Pain\n Assessment:\n Pt c/o generalized intermittent pain, especially when turning. Pt has\n on fentanyll patches in place on left upper arm.\n Action:\n Pt also has fent lollipop from home for breakthrough pain if needed.\n Needed x1 lollipop today.\n Response:\n Currently pt is comfortable. Hums w/ turning to aleviate pain.\n Plan:\n Resumeing all meds today, held methadone as MD\ns did not want him\n somulent today.\n Pneumonia, aspiration\n Assessment:\n Cxr and ct scan suggestive of aspiration pna. Pt\ns now afebrile\n Action:\n Pt started on vanco/ zosyn/ levoflox. Urine cx sent d/t freq uti\n Response:\n No c/o difficutly breathing.\n Plan:\n Cont antibx follow cultures. Get sputum cx if pt can expectorate.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 78.8 kg\n Daily weight:\n Allergies/Reactions:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Precautions:\n PMH:\n CV-PMH:\n Additional history: chronic uti's, multiple deucub's, dvt's, sleep\n apnea, chronic pain, osteo, transverse myelitis (parapalegic)\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:73\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 100% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 822 mL\n 24h total out:\n 1,330 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 05:09 AM\n Potassium:\n 3.4 mEq/L\n 05:09 AM\n Chloride:\n 92 mEq/L\n 05:09 AM\n CO2:\n 34 mEq/L\n 05:09 AM\n BUN:\n 5 mg/dL\n 05:09 AM\n Creatinine:\n 0.5 mg/dL\n 05:09 AM\n Glucose:\n 104 mg/dL\n 05:09 AM\n Hematocrit:\n 28.5 %\n 05:09 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 788\n Transferred to: CC709\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2164-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370036, "text": "Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment. Vanc trough 28.5 at AM .\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate.\n AM dose of vanc not given. Vanc order changed to QD.\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due. NC trial during night .\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n Fentanyl IV 25 mcg X1 given. Ativan IV q 4 hourly given. Hallodol 2\n mg IV given. See metavision for details.\n Response:\n Pt currently is restless, awake throughout the day. Exhausted toward\n the evening. Denies pain, continues to refuse PO meds, MD aware. RR\n at30-40\ns when agitated. At rest RR at 20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1400 hrs : 72.7\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n PTT goal 60-100.\n" }, { "category": "Nursing", "chartdate": "2164-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370037, "text": "Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate.\n vanc not given.\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n given. Ativan IV q 4 hourly given. Hallodol 2 mg IV given. See\n metavision for details.\n Response:\n Pt calm and sleeping. Denies pain, continues to refuse PO meds, MD\n aware. RR at30-40\ns when agitated. At rest RR at 20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1300 hrs : 72.7\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n PTT goal 60-100.possible change to Lovenox\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home . cont d5%1/2 NS at 75 cc/hr\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.start PPN nad given lipids 20%\n over 6hr\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370038, "text": "Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs\n Action:\n Nebs q6h, remains on NRB, placed pt on NC 3L, but pt desat to 89. vanc\n not given.\n Response:\n Satting high 90\ns., RR 10-30\ns. cont NRB.\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n given. Ativan IV q 4 hourly given. Hallodol 2 mg IV given. See\n metavision for details.\n Response:\n Pt calm and sleeping. Denies pain, continues to refuse PO meds, MD\n aware. RR at30-40\ns when agitated. At rest RR at 20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1300 hrs : 72.7\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n PTT goal 60-100.possible change to Lovenox\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home . cont d5%1/2 NS at 75 cc/hr\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.start PPN nad given lipids 20%\n over 6hr\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370041, "text": "Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns continues on vacno/zosyn/levaquin, no sputum\n culture as pt unable to produce. Patient refused nebs\n Action:\n Nebs q6h, remains on NRB, placed pt on NC 3L, but pt desat to 89. vanc\n not given.\n Response:\n Satting high 90\ns., RR 10-30\ns. cont NRB.\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n given. Ativan IV q 4 hourly given. Hallodol 2 mg IV given. See\n metavision for details.\n Response:\n Pt calm and sleeping. Denies pain, continues to refuse PO meds, MD\n aware. RR at30-40\ns when agitated. At rest RR at 20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1300 hrs : 72.7\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n PTT goal 60-100.possible change to Lovenox\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home . cont d5%1/2 NS at 75 cc/hr\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.start PPN nad given lipids 20%\n over 6hr\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Physician ", "chartdate": "2164-02-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 369739, "text": "Chief Complaint: Dyspnea\n HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Levofloxacin - 03:08 PM\n Infusions:\n Heparin Sodium - 2,000 units/hour\n Other medications:\n Heparin drip\n Vancomycin\n Levofloxacin\n Zosyn\n Clonazepam\n Colace\n Duragesic\n Baclofen\n Omeprazole\n Singulair\n Mexilitine\n Methadone\n Theophyllline\n Past medical history:\n Family history:\n Social History:\n Sampters Syndrome: asa sensitivity, nasal polyps, asthma\n Transverse myelitis - since 's related to viral infection\n Anxiety\n Chronic Pain\n Asthma\n Non-contributory\n Occupation: Former physicist - worked in optics\n Drugs:\n Tobacco: Remote history of smoking\n Review of systems:\n As per resident admission note\n Flowsheet Data as of 04:10 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 108 (108 - 108) bpm\n BP: 135/66(82) {135/66(82) - 135/66(82)} mmHg\n RR: 18 (18 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 152 mL\n PO:\n TF:\n IVF:\n 152 mL\n Blood products:\n Total out:\n 0 mL\n 890 mL\n Urine:\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -738 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 100%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 633 K/uL\n 28.5 %\n 9.6 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 5 mg/dL\n 34 mEq/L\n 92 mEq/L\n 3.4 mEq/L\n 132 mEq/L\n 13.6 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 13.6\n Hct\n 28.5\n Plt\n 633\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 104\n Other labs: PT / PTT / INR:14.6/28.2/1.3, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 62M with h/o transverse myelitis, sampter's triad, asthma; admitted\n with clinical course that is a fairly rapid deterioration in his\n respiratory status, waxing and degress of severe hypoxemia, and\n evidence of severe bilateral ground glass opacities superimposed on\n possible ILD with peripheral fibrosis. At this point, the differential\n includes possible recurrent aspiration events and chemical pneumonits.\n The cllinical course seems too rapid for ILD; though it is possible he\n had subclinical progression given some evidence of underlying fibrosis\n (? UIP/NSIP, possible related to recurrent aspiration); and this is an\n exacerbation of a previously unrecognized chronic process such as UIP.\n As for infectious etiologies, he has been covered with\n vancomycin/zosyn/levofloxacin, and we have been unable to obtain sputum\n samples. He is not at particular risk of opportunistic infections as\n he has not been prescribed prednisone and does not have any known\n malignancy. Eosinophilic disease is possible, but also seems unlikely.\n He is in a difficult situation at the present time. His degree of\n hypoxemia precludes bronchoscopy without prompting intubation, and\n would not desire to intubate for bronch given predicted difficulty in\n extubation were that to occur. Ideally, will await some degree of\n improvement of his oxygenation, then perhaps can undertake bronchoscopy\n safely. Alternatively, if he gets worse and requires intubation and\n mechanical ventilation; could potentially bronch and BAL at that time.\n Am also reluctant to start empiric steroids without any clear diagnosis\n and some concern for infection.\n 1. Hypoxemic Respiratory Failure - ddx as above. Currently his O2 is\n slowly improving\n - will continue to monitor\n - Treat for infx etiologies\n - obtain sputum if produces\n - Intubate if worsens\n - Will consider bronchoscopy if he improves or he requires intubation\n - Await ANCA, IgE; please make sure anti-GBM is sent\n 2. GI: he has a large patulous esophagus, and there is concern for\n silent aspiration.\n - Will discuss GI if can obtain an esophageal pH probe to evaluate for\n aspiration\n - Start PPI\n - HOB elevated\n 3. ID - Afebrile, but does have leukocytosis. Doubt infectious\n etiology, but favor continuation of antibiotics given clinical status\n - continue vancomycin, levofloxacin, zosyn\n - Please send LDH\n - B glucan/galactommanan\n - Sputum culture if possible; send for routine culture/gram stain;\n PCP, stain/culture\n 4. FEN:\n - will need NGT placement once oxygenation improves\n 5. Psych: Has significant anxiety; not clear if anxiety is secondary to\n his hypoxemia. He is chronically on xanax.\n - If requires additional medications for anxiety, would trial of haldol\n or zyprexa.\n - Can continue home dose of xanax with careful monitoring.\n ICU Care\n Nutrition:\n Holding enteral feeds pending\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 01:22 PM\n 20 Gauge - 01:23 PM\n Comments:\n Prophylaxis:\n DVT: Heparin drip for DVT\n Stress ulcer: PPI\n Communication: Comments: Spoke with family, communicated plan\n Code status: FULL CODE\n Disposition: ICU\n Total time spent: 45 minutes\n ------ Protected Section ------\n I was physically present with the housestaff team and independently\n examined the patient on this date. I would agree in full with the note\n above and would add the following comments\n Patient with clear history of onset and persistence of diffuse ground\n glass opacities dominant in the lower lobes. The infiltrates and his\n hypoxia have been quite persistent which would argue against a rapidly\n progressive interstitial lung disease such as AIP. Infection may well\n be slow to clear and aspiration pneumonitis if driving this may result\n in persistence of pneumonitis in the setting of persistence of\n aspiration events. What remains possible but undiagnosed are disorders\n such as eosinophillic pneumonia or NSIP or alternative ILD which would\n require biopsy or bronch for documentation neither of which are likely\n to be well tolerated. There is no evidence for hydrostatic edema.\n Lung Exam\nDiffuse crackles and end inspiration, no wheezes, no dullness\n to percussion.\n Will\n -Continue ABX\n -Support with O2 as needed\n -Consult Gi for question of pH probe to look for silent aspiration\n -Will not pursue empiric steroids due to absence of diagnosis and\n significant SE\n Critical Care Time-35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 19:13 ------\n" }, { "category": "Physician ", "chartdate": "2164-02-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 369473, "text": "Chief Complaint: Shortness of breath\n HPI:\n 62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. The\n patient has had a complicated recent history involving a tib/fib fx\n sustained while moving in his wheel chair. This was not treated\n surgically. He also has a sacral decub which was treated with 2 weeks\n of cipro then 2 weeks of levofloxacin. Over the past two days he has\n been having increasing shortness of breath. He has oxygen at home which\n he normally does not use. He has been using up to 4L 1 day PTA. He\n reports no fevers of chills. He has been taking his temp and no\n documented fevers. He does not endorse ant chest pain. His wife notes\n that although his right leg is constantly swollen from the fracture,\n his left leg has been having increasing swelling over the past few\n days. His wife also notes that he has been increasingly lethargic over\n the past few days as well.\n .\n In the ED, he recieved Vanc and Zosyn. CTA neg for PE but showed no\n central PE but bibasal GGO and more consolidative opc w/enlarged\n subcarinal ? pna (preliminary read). The Medicine housetaff\n discussed scan with Pulmonary, who felt this scan likely represented\n aspiration, or CHF, less likely ILD.\n .\n Upon arrival to the medicine floor his sats were in the 80s on NC and\n he required a NRB to attain sats in the 90s. An ABG was performed\n 7.49/44/141. He was given 20mg IV lasix. He was eventually able to be\n placed on a 40% venturi mask. His oral temp was 99.7. He was short of\n breath when not on the NRB. The patient is being transferred to the\n MICU for higher level of nursing care and closer monitoring given\n fluctuating oxygen requirement.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain,\n nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,\n dysuria, hematuria.\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n TRANSVERSE MYELITIS: virus in 90s.\n CHRONIC PAIN\n CHRONIC UTI\n NEUROGENIC BLADDER\n DEPRESSION\n ASTHMA\n CONSTIPATION\n NASAL POLYPS\n BURSITIS - R HIP\n DECUBITUS ULCER\n SYNDROME\n Non-contributory\n Occupation: None\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Lives with wife who is primary caretaker\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, Edema, No(t) Orthopnea\n Respiratory: Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice, erythema legs B\n Neurologic: hx paraplegia\n Pain: Minimal\n Pain location: decubiti\n Flowsheet Data as of 02:25 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 103 (103 - 117) bpm\n BP: 109/65(73) {109/65(73) - 120/75(83)} mmHg\n RR: 14 (14 - 22) insp/min\n SpO2: 100%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -500 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 100%\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, anicteric\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Fine, scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, erythema/warmth scattered on both\n legs\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 686\n 149\n 0.5\n 5\n 31\n 90\n 3.9\n 129\n 29.3\n 16.4\n [image002.jpg]\n Other labs: Differential-Neuts:87.3, Lactic Acid:1.1\n Fluid analysis / Other labs: BNP 722\n CK/trop neg x 2\n ABG: 7.49/44/141/34\n Imaging: Chest CT: CTA neg for PE but showed no central PE but Bibasal\n GGO and more consolidative opc w/enlarged subcarinal ? pna.\n Microbiology: Blood cx: P\n Urine cx : P\n Sputum cx: P\n ECG: ST NA/NI, NSST-T changes similar to prior\n Assessment and Plan\n 62M paraplegic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: CTA r/o PE but showed mostly dependent GGO, ? aspiration\n PNA/pneumonitis vs CAP vs ILD vs pulmonary edema. Leukocytosis of 16.4,\n lactate 1.1. No wheezing to suggest asthma exacerbation. There has been\n some concern in the past of the pt aspirating.\n - Vanco/Zosyn/levaquin for now, then narrow\n - Sputum cx\n - Pulmonary c/s in AM (already reviewed CT scans)\n - F/U final read of CT scan\n - Cautious diuresis, pt has improved after diuresis on floor\n - Would hold on steroids for now as likely infectious vs chemical\n pneumonitis\n - Formal S&S eval in AM\n .\n # LE Edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n - Vanco will cover cellulitis\n - LENIs to r/o DVT\n - Gentle diuresis\n - Check albumin\n - TTE tomorrow for cardiac function\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levaquin as outpatient, scheduled for Plastics\n eval tomorrow as outpatient.\n - Wound care consult in AM\n - Plastics consult\n - Current antibiotics should cover for now\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n .\n # PPX: PPI, heparin SQ, bowel regimen\n .\n # ACCESS: PIV\n .\n # CODE: Full\n .\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n .\n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines: PIV\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2164-02-15 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 369477, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o m w paraplegia, asthma p/w SOB and LE edema to ED yesterday. CTA\n done showed no PE, but bilat lower lobe GGO, concerning for aspiration\n or CHF. Given vanco and zosyn in ED. Sat 80% on NC. 7.49.44.141 on NRB.\n Given 20 mg IV lasix. Went initially to the floor, then sent here for\n concerning oxygen requirement.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Vancomycin - 03:37 AM\n Levofloxacin - 05:14 AM\n Infusions:\n Other ICU medications:\n Other medications:\n albuterol, alprazolam, baclofen, buproprion, zyrtec, clonazepam,\n fentanyl patch, lactulose, levothyroxine, mexilitine, singulair,\n omeprazole, miralax, theophylline\n Past medical history:\n Family history:\n Social History:\n Transverse myelitis c/b paraplegia\n Chronic Foley\n Sacral Decubs\n Tib/fib fx\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives with wife\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Flowsheet Data as of 09:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.4\nC (97.5\n HR: 97 (96 - 117) bpm\n BP: 102/58(69) {98/55(65) - 120/75(83)} mmHg\n RR: 15 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -540 mL\n Respiratory\n O2 Delivery Device: Venti mask\n FiO2: 0.35\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : bibasilar)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 633 K/uL\n 28.5 %\n 9.6 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 5 mg/dL\n 34 mEq/L\n 92 mEq/L\n 3.4 mEq/L\n 132 mEq/L\n 13.6 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 13.6\n Hct\n 28.5\n Plt\n 633\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 104\n Other labs: PT / PTT / INR:14.6/28.2/1.3, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n HYPOXEMIA\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n CHRONIC PAIN\n Plan:\n 1. Hypoxemia: Possible asp PNA vs. CAP vs. Inflammatory process vs. CHF\n -cont. gentle diuresis, although BNP 700\n -check sputum cx\n -concerning for inflammatory process as well, although seems to be\n improving\n -TTE\n -plan for repeat CT in a few days\n -vanco/zosyn/levaquin\n -swallow eval\n 2. Chronic pain: cont. methadone and fentanyl\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 18 Gauge - 02:37 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "General", "chartdate": "2164-02-15 00:00:00.000", "description": "Generic Note", "row_id": 369484, "text": "TITLE: Bedside Evaluation\n Pt was seen for a bedside evaluation and tolerated thin liquids\n and soft consistency solids without overt signs of aspiration. Please\n see Web OMR or paper chart for additional details.\n , MS, CCC-SLP\n Pager#\n 10:12\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369930, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n PCP discussed hospice care with pt and family today, started on\n halodol 2 mg IV as PRN basis. Geriatric consulted. Pt has been\n refusing all PO\ns except ice chips since last night.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LS rhonchorous bilaterally,\n diminished at bases; continues on vacno/zosyn/levaquin, no sputum\n culture as pt unable to produce. Patient refused nebs treatment.\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given.\n Hallodol 2 mg IV X1 given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware. RR at 16-20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs, pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370025, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment. Vanc trough 28.5 at AM .\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate.\n AM dose of vanc not given. Vanc order changed to QD.\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n Fentanyl IV 25 mcg X1 given. Ativan IV q 4 hourly given. Hallodol 2\n mg IV X1 given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware. RR at 16-20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs, pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369826, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI \n Respiratory Failure\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting 100% currently, RR teens, regular, appears comfortable\n Plan:\n Cont to monitor resp status, nebs q6h\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound care\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches and fent buccal for\n breakthrough\n Action:\n Response:\n Currently pt is comfortable. Hums w/ turning to aleviate pain.\n Plan:\n Resumeing all meds today, held methadone as MD\ns did not want him\n somulent today.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369828, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n EVENTS: beginning of shift, pt requesting bedpan, family left room to\n waiting room, bedpan given, shortly afterwards, pt began yelling out,\n agitated, asking for\nshot\n, fentanyl given per prn orders, family\n called and returned to bedside, pt extremely agitated, then asking for\nshot for panic\n, given ativan IVP, took approx\n hour for pt to\n recover from episode, during that time he was tachypneic to 30\n desatting to 80\ns, very anxious; pt settled; patient\ns wife requesting\n for assistance getting bedpan out from under pt; 2 RN\ns turning pt, as\n pt\ns wife yelling at staff for being too rough, wife picked up bedpan\n and threw it at this RN, then began yelling at another RN, escalating\n and screaming in her face, wife then walked out of room, this RN\n attempting to calm wife, wife and pt\ns brother left unit; wife\n returned, behavior appropriate, wife apologized to staff, Clinical\n Supervisor notified and spoke with family members, no further issues\n with family tonight\n Today, PCP to come in and discuss CMO with pt and family\n Respiratory Failure, Chronic\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting 100% currently, RR teens, regular, appears comfortable\n Plan:\n Cont to monitor resp status, nebs q6h\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound care\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax and prn xanax; tonight pt\n had episode where he became agitated and anxious, requesting a\nshot\n for panic\n , yelling out, unable to calm pt, desatting to 80\ns, RR to\n 30\n Action:\n Pt family called to be at patient\ns bedside, given prn fentanyl and one\n time order of ativan; attemped to administer patient\ns standing xanax\n and methadone throughout shift but pt refusing\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse xanax, also unable to give all other PO meds, MD\n aware\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @ 2100 units/hr, +PP bilaterally,\n bilateral 3+ pitting edema\n Action:\n Following PTT\n Response:\n Last PTT therapeutic, 82.6\n Plan:\n Daily PTT, gtt therapeutic, goal 60-100\n Alteration in Nutrition\n Assessment:\n Poor PO intake, weight loss of 40 lbs over\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369829, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n EVENTS: beginning of shift, pt requesting bedpan, family left room to\n waiting room, bedpan given, shortly afterwards, pt began yelling out,\n agitated, asking for\nshot\n, fentanyl given per prn orders, family\n called and returned to bedside, pt extremely agitated, then asking for\nshot for panic\n, given ativan IVP, took approx\n hour for pt to\n recover from episode, during that time he was tachypneic to 30\n desatting to 80\ns, very anxious; pt settled; patient\ns wife requesting\n for assistance getting bedpan out from under pt; 2 RN\ns turning pt, as\n pt\ns wife yelling at staff for being too rough, wife picked up bedpan\n and threw it at this RN, then began yelling at another RN, escalating\n and screaming in her face, wife then walked out of room, this RN\n attempting to calm wife, wife and pt\ns brother left unit; wife\n returned, behavior appropriate, wife apologized to staff, Clinical\n Supervisor notified and spoke with family members, no further issues\n with family tonight\n Today, PCP to come in and discuss CMO with pt and family\n Respiratory Failure, Chronic\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting 100% currently, RR teens, regular, appears comfortable\n Plan:\n Cont to monitor resp status, nebs q6h\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound care\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax and prn xanax; tonight pt\n had episode where he became agitated and anxious, requesting a\nshot\n for panic\n , yelling out, unable to calm pt, desatting to 80\ns, RR to\n 30\n Action:\n Pt family called to be at patient\ns bedside, given prn fentanyl and one\n time order of ativan; attemped to administer patient\ns standing xanax\n and methadone throughout shift but pt refusing\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse xanax, also unable to give all other PO meds, MD\n aware\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @ 2100 units/hr, +PP bilaterally,\n bilateral 3+ pitting edema\n Action:\n Following PTT\n Response:\n Last PTT therapeutic, 82.6\n Plan:\n Daily PTT, gtt therapeutic, goal 60-100\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, started D5\n @ 100cc/hr x 500cc\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369832, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n EVENTS: beginning of shift, pt requesting bedpan, family left room to\n waiting room, bedpan given, shortly afterwards, pt began yelling out,\n agitated, asking for\nshot\n, fentanyl given per prn orders, family\n called and returned to bedside, pt extremely agitated, then asking for\nshot for panic\n, given ativan IVP, took approx\n hour for pt to\n recover from episode, during that time he was tachypneic to 30\n desatting to 80\ns, very anxious; pt settled; patient\ns wife requesting\n for assistance getting bedpan out from under pt; 2 RN\ns turning pt, as\n pt\ns wife yelling at staff for being too rough, wife picked up bedpan\n and threw it at this RN, then began yelling at another RN, escalating\n and screaming in her face, wife then walked out of room, this RN\n attempting to calm wife, wife and pt\ns brother left unit; wife\n returned, behavior appropriate, wife apologized to staff, Clinical\n Supervisor notified and spoke with family members, no further issues\n with family tonight\n Today, PCP to come in and discuss CMO with pt and family\n Respiratory Failure, Chronic\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting 100% currently, RR teens, regular, appears comfortable\n Plan:\n Cont to monitor resp status, nebs q6h\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound care\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax;\n tonight pt had episode where he became agitated and anxious, requesting\n a\nshot for panic\n , yelling out, unable to calm pt, desatting to 80\n RR to 30\n Action:\n Pt family called to be at patient\ns bedside, given prn fentanyl and one\n time order of ativan; attemped to administer patient\ns standing xanax\n and methadone throughout shift but pt refusing\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse xanax, also unable to give all other PO meds, MD\n aware\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @ 2100 units/hr, +PP bilaterally,\n bilateral 3+ pitting edema\n Action:\n Following PTT\n Response:\n Last PTT therapeutic, 82.6\n Plan:\n Daily PTT, gtt therapeutic, goal 60-100\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, started D5\n @ 100cc/hr x 500cc\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370029, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment. Vanc trough 28.5 at AM .\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate.\n AM dose of vanc not given. Vanc order changed to QD.\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due. NC trial during night .\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n Fentanyl IV 25 mcg X1 given. Ativan IV q 4 hourly given. Hallodol 2\n mg IV given. See metavision for details.\n Response:\n Pt currently is restless, awake throughout the day. Exhausted toward\n the evening. Denies pain, continues to refuse PO meds, MD aware. RR\n at30-40\ns when agitated. At rest RR at 20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT\n Response:\n Heparin gtt @\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs, pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate. Fat emulsion to\n be administered ( awaiting for clarification from resident).\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370030, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment. Vanc trough 28.5 at AM .\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate.\n AM dose of vanc not given. Vanc order changed to QD.\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due. NC trial during night .\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n Fentanyl IV 25 mcg X1 given. Ativan IV q 4 hourly given. Hallodol 2\n mg IV given. See metavision for details.\n Response:\n Pt currently is restless, awake throughout the day. Exhausted toward\n the evening. Denies pain, continues to refuse PO meds, MD aware. RR\n at30-40\ns when agitated. At rest RR at 20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1400 hrs : 72.7\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n Q8 h PTT, goal 60-100. Next PTT at\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate. Fat emulsion to\n be administered ( awaiting for clarification from resident).\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370031, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect when not given\n together . Patient is not able to take nap throughout the day due to\n his frequent anxiety attack. Obssessed with his demands.\n Yelles/screams frequently. Patient\ns wife is at bedside throughout the\n day. Fentanyl patch 200 mcg/hr placed at rt upper thigh. Fentanyl 25\n mcg X1 given. Patient denies pain throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen trial & 2 L NC,\n satt at low 90\ns, but patient freaked out when he realized that he is\n off oxygen. RR -40\ns, desat at 80\ns, very restless, placed back on\n Rebreather mask 100%. Since then patient has been requesting for nasal\n cannula & rebreather mask but maintains sat at high 90\ns on\n rebreather.\n Psych, , palliative care following up. Patient will go to home with\n hospice probably.\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt anxious , tachypneic to 30\ns- 40\n when agitated, RR 20-30\ns otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment. Vanc trough 28.5 at AM .\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate.\n AM dose of vanc not given. Vanc order changed to QD.\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible. Vanc trough AM due. NC trial during night .\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Mepilex in place, intact.\n Response:\n No changes .\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches (placed @ rt upper thigh\n on at 1600 hrs), . Patient refused all PO meds. Request\n frequently for IV meds to calm him down.\n Action:\n Fentanyl IV 25 mcg X1 given. Ativan IV q 4 hourly given. Hallodol 2\n mg IV given. See metavision for details.\n Response:\n Pt currently is restless, awake throughout the day. Exhausted toward\n the evening. Denies pain, continues to refuse PO meds, MD aware. RR\n at30-40\ns when agitated. At rest RR at 20\ns. satting at mid 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level . Monitoring EKG for QTC.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT. Last PTT at 1400 hrs : 72.7\n Response:\n Heparin gtt @ 1500 units/hr\n Plan:\n PTT goal 60-100.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate. Fat emulsion to\n be administered ( awaiting for clarification from resident).\n" }, { "category": "Nursing", "chartdate": "2164-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369465, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. The\n patient has had a complicated recent history involving a tib/fib fx\n sustained while moving in his wheel chair. This was not treated\n surgically. He also has a sacral decub which was treated with 2 weeks\n of cipro then 2 weeks of levofloxacin. Over the past two days he has\n been having increasing shortness of breath. He has oxygen at home which\n he normally does not use. He has been using up to 4L 1 day PTA. He\n reports no fevers of chills. He has been taking his temp and no\n documented fevers. He does not endorse ant chest pain. His wife notes\n that although his right leg is constantly swollen from the fracture,\n his left leg has been having increasing swelling over the past few\n days. His wife also notes that he has been increasingly lethargic over\n the past few days as well.\n .\n In the ED, he recieved Vanc and Zosyn. CTA neg for PE but showed no\n central PE but bibasal GGO and more consolidative opc w/enlarged\n subcarinal ? pna (preliminary read). The Medicine housetaff\n discussed scan with Pulmonary, who felt this scan likely represented\n aspiration, or CHF, less likely ILD.\n .\n Upon arrival to the medicine floor his sats were in the 80s on NC and\n he required a NRB to attain sats in the 90s. An ABG was performed\n 7.49/44/141. He was given 20mg IV lasix. He was eventually able to be\n placed on a 40% venturi mask. His oral temp was 99.7. He was short of\n breath when not on the NRB. The patient is being transferred to the\n MICU for higher level of nursing care and closer monitoring given\n fluctuating oxygen requirement.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain,\n nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,\n dysuria, hematuria.\n Hypoxemia\n Assessment:\n Pt arrived in micu with 100% nrb mask with o2 sat\ns @ 100%. Lung sounds\n clear with crackles at the bases. Pt was somewhat anxious when first\n arrived, hr st with rates in the one teens. Bp wnl.\n Action:\n Pt made comfortable. Replaced nrb mask with ventimask at 50%. Pt had\n received 40mg of iv lasix prior to transferring to the unit.\n Response:\n Pt with foley cath inplace and was draining lrg amt\ns of clear yellow\n urine, o2 sat\ns on venti mask remained at 100%. By morning pt c/o nasal\n passages were very dry, venti mask then chg\nd to 40% open face tent. O2\n sat\ns cont to be in the high 90\ns to 100%. Lung sounds improving. MRSA\n swab sent.\n Plan:\n Cont to monitor resp status.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubiti on sacral area and buttocks.\n Action:\n Pt s\n wife had placed dressings on open decub\ns prior to transferr. Pt\n has special air pillow that he brought from home. All dressings intact.\n Response:\n Will need a skin consult today.\n Plan:\n Assess areas with skin nurse.\n Chronic Pain\n Assessment:\n Pt c/o generalized intermittent pain, especially when turning. Pt has\n on fentanyll patches in place on left upper arm.\n Action:\n Pt has refused all pills until later this morning. Pt also has fent\n lollipop for pain if needed.\n Response:\n Currently pt is comfortable\n Plan:\n Resume all meds as tolerated today\n" }, { "category": "Nursing", "chartdate": "2164-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369466, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. The\n patient has had a complicated recent history involving a tib/fib fx\n sustained while moving in his wheel chair. This was not treated\n surgically. He also has a sacral decub which was treated with 2 weeks\n of cipro then 2 weeks of levofloxacin. Over the past two days he has\n been having increasing shortness of breath. He has oxygen at home which\n he normally does not use. He has been using up to 4L 1 day PTA. He\n reports no fevers of chills. He has been taking his temp and no\n documented fevers. He does not endorse ant chest pain. His wife notes\n that although his right leg is constantly swollen from the fracture,\n his left leg has been having increasing swelling over the past few\n days. His wife also notes that he has been increasingly lethargic over\n the past few days as well.\n .\n In the ED, he recieved Vanc and Zosyn. CTA neg for PE but showed no\n central PE but bibasal GGO and more consolidative opc w/enlarged\n subcarinal ? pna (preliminary read). The Medicine housetaff\n discussed scan with Pulmonary, who felt this scan likely represented\n aspiration, or CHF, less likely ILD.\n .\n Upon arrival to the medicine floor his sats were in the 80s on NC and\n he required a NRB to attain sats in the 90s. An ABG was performed\n 7.49/44/141. He was given 20mg IV lasix. He was eventually able to be\n placed on a 40% venturi mask. His oral temp was 99.7. He was short of\n breath when not on the NRB. The patient is being transferred to the\n MICU for higher level of nursing care and closer monitoring given\n fluctuating oxygen requirement.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain,\n nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,\n dysuria, hematuria.\n Hypoxemia\n Assessment:\n Pt arrived in micu with 100% nrb mask with o2 sat\ns @ 100%. Lung sounds\n clear with crackles at the bases. Pt was somewhat anxious when first\n arrived, hr st with rates in the one teens. Bp wnl.\n Action:\n Pt made comfortable. Replaced nrb mask with ventimask at 50%. Pt had\n received 40mg of iv lasix prior to transferring to the unit.\n Response:\n Pt with foley cath inplace and was draining lrg amt\ns of clear yellow\n urine, o2 sat\ns on venti mask remained at 100%. By morning pt c/o nasal\n passages were very dry, venti mask then chg\nd to 40% open face tent. O2\n sat\ns cont to be in the high 90\ns to 100%. Lung sounds improving. MRSA\n swab sent.\n Plan:\n Cont to monitor resp status.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubiti on sacral area and buttocks.\n Action:\n Pt s\n wife had placed dressings on open decub\ns prior to transferr. Pt\n has special air pillow that he brought from home. All dressings intact.\n Response:\n Will need a skin consult today.\n Plan:\n Assess areas with skin nurse.\n Chronic Pain\n Assessment:\n Pt c/o generalized intermittent pain, especially when turning. Pt has\n on fentanyll patches in place on left upper arm.\n Action:\n Pt has refused all pills until later this morning. Pt also has fent\n lollipop for pain if needed.\n Response:\n Currently pt is comfortable\n Plan:\n Resume all meds as tolerated today\n Pneumonia, aspiration\n Assessment:\n Cxr and ct scan suggestive of aspiration pna. Pt\ns temp max 100.3 po\n wbc 16\n Action:\n Pt started on vanco/ zosyn/ levoflox. Urine cx sent d/t freq uti\n Response:\n Pt\ns temp down to 97.7\n Plan:\n Cont antibx follow cultures.\n" }, { "category": "Nursing", "chartdate": "2164-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369825, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on\n Hypoxemia\n Assessment:\n Started shift on 35% humidified face mask, o2sat 100%\n Action:\n Placed on 4L nc while taking meds, placed back on 35% humidified face\n mask per pt request. ECHO for ? CHF and lower extremity US. Started on\n Hep gtt w/ 3000Unit bolus to start.\n Response:\n Tolerated 4L NC but preferred the humidified air. C/O dry throat and\n dry tissue build up in the back of his throat when too long on NC. (on\n and off NC @ home). ECHO results pending, LENI showed DVT.\n Plan:\n Cont to monitor resp status, nebs, Pulmonary consult to be ordered, ?\n bronch eventually and/or repeat chest CT for ? interstitial process.\n Next PTT for Hep gtt is 2000pm.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubiti on sacral area and buttocks and sm. Area on\n medial R knee from brace.\n Action:\n Wound care consult, incident report (chronic wounds from home),\n plastics consult, dsgs changed per wound care rec\ns, ordered first step\n bed w/ MRS \n Response:\n Plastics will follow and discuss a plan, ortho consult for tib/fib\n fracture (brace on R leg causing knee pressure ulcer), dsg\ns remain\n intact\n Plan:\n Plastics to determine plan for Stage 4 on R glute/ishial area (?\n Osteomyelitis now as well), change stage 4dsg QD and others PRN or\n Q3days if dsg\ns remain intact.\n Chronic Pain\n Assessment:\n Pt c/o generalized intermittent pain, especially when turning. Pt has\n on fentanyll patches in place on left upper arm.\n Action:\n Pt also has fent lollipop from home for breakthrough pain if needed.\n Needed x1 lollipop today.\n Response:\n Currently pt is comfortable. Hums w/ turning to aleviate pain.\n Plan:\n Resumeing all meds today, held methadone as MD\ns did not want him\n somulent today.\n Pneumonia, aspiration\n Assessment:\n Cxr and ct scan suggestive of aspiration pna. Pt\ns now afebrile\n Action:\n Pt started on vanco/ zosyn/ levoflox. Urine cx sent d/t freq uti\n Response:\n No c/o difficutly breathing.\n Plan:\n Cont antibx follow cultures. Get sputum cx if pt can expectorate\n" }, { "category": "Nursing", "chartdate": "2164-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 370016, "text": "62 year old male with history of transverse myelitis complicated by\n paraplegia who presents with two days of shortness of breath. recent\n history tib/fib fx sustained while moving in his wheel chair, sacral\n decubitis, also with aspiration pna, CTA neg for PE, but has bilateral\n ground glass opacities, RLE DVT on heparin gtt; was transferred out to\n floor on , readmitted to MICU 7 with worsening respiratory failure\n asp pna vs interstitial lung disease; code status changed to\n DNR/DNI , meeting with palliative care\n Significant events on :\n *** Panick /anxiety attack frequently\n throughout the day , requesting IV anti-anxiety medication . IV ativan\n increased to 1-2 mg IV Q 4 hourly, IV halodol increased to 4 mg\n hourly. Haldol IV & Ativan IV with minimal affect . Patient is not\n able to take nap throughout the day due to his frequent anxiety attack.\n Obssessed with his demands. Yelles/screams frequently. Patient\ns wife\n is at bedside throughout the day. Fentanyl patch 200 mcg/hr placed at\n rt upper thigh. Fentanyl 25 mcg X1 given. Patient denies pain\n throughout the day.\n 2 nd day on steroids IV. Denies all PO meds but took PO xanax X1.\n Received patient on non-rebreather 100%. Off oxygen for 10 mins , satt\n at low 90\ns, but patient freaked out when he\n Respiratory Failure, Chronic/ Pnuemonia, Aspiration\n Assessment:\n Received on NRB, unable to remove except for brief periods to do mouth\n care and give pt ice chips, as pt desats to 80\ns, tachypneic to 30\n when agitated, RR in teens otherwise; LSCTA bilaterally; continues on\n vacno/zosyn/levaquin, no sputum culture as pt unable to produce.\n Patient refused nebs treatment.\n Action:\n Nebs q6h, remains on NRB, no weaning attempted as pt does not tolerate\n Response:\n Satting high 90\ns., RR 10-30\n Plan:\n Cont to monitor resp status, nebs q6h, continue abx, send sputum if\n possible\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt has multiple decubitus ulcers on sacral area and ischial spines,\n small area on medial R knee from brace, see flowsheet\n Action:\n Sacral dsg intact, ischial spine wound dressings changed per wound\n care, stage 4 dsg not changed\n Response:\n No changes\n Plan:\n Plastics c/s for stage 4 wound; change dsg as needed for drainage,\n otherwise change q3d\n Chronic Pain/Anxiety\n Assessment:\n Pt with chronic pain, on fentanyl patches, methadone, and fent buccal/\n IVP for breakthrough, also on scheduled xanax, klonopin, and prn xanax.\n Patient refused all PO meds. Request frequently for IV meds to calm him\n down.\n Action:\n Fentanyl IV 25 mcg X2 given. Ativan 0.50 mg IV q 4 hourly given.\n Hallodol 2 mg IV X1 given.\n Response:\n Pt currently is calm, sleeping off and on during shift, denies pain,\n continues to refuse PO meds, MD aware. RR at 16-20\ns. satting at mid\n 90\ns now.\n Plan:\n Pain and anxiety meds scheduled and prn as tolerated by patient,\n continue to monitor pt pain level\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n RLE DVT s/p tib/fib fx on heparin gtt @1500 units/hr. , +PP\n bilaterally, bilateral 3+ pitting edema\n Action:\n Following PTT, last PTT 150. heparin gtt stopped for 60 mins, resumed @\n 1500 units /hr .\n Response:\n Heparin gtt resumed at 1500 units/hr at 1500 hrs.\n Plan:\n Q6h PTT, goal 60-100. Next PTT at 1800 hrs, pending.\n Alteration in Nutrition\n Assessment:\n Poor PO intake, cachetic, weight loss of 40 lbs over 2 years, pureed\n foods at home; D5\n with 40 meq KCl x1 L complete\n Action:\n Encouraged PO intake, D5\n NS at 75 cc/hr . Speech & swallow eval\n pending as patient does not co-operate.\n Response:\n Pt refusing most things, ie meds, will take ice chips\n Plan:\n Will eval for PPN, continue to encourage PO intake as tolerated,\n supervise with all PO intake; will rec addt\nl 1L D5\n @ 75 cc/hr .\n Speech & swallow eval when patient is more appropriate.\n" }, { "category": "Physician ", "chartdate": "2164-02-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 369720, "text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n 62-year-old man quadraplegic s/p transverse myelitis, h/o asthma,\n multiple pnas, initially admitted on for hypoxia, concerning\n for pna, temporarily in ICU on for hypoxia, now transferred\n back to ICU from floor for frequent hypoxic episodes.\n Allergies:\n Aspirin\n Samter's syndro\n Erythromycin Base\n Unknown;\n Iodine; Iodine Containing\n Unknown;\n Cottonseed Oil\n Unknown;\n Ceftazidime\n Rash;\n Clindamycin\n Hives; Rash;\n Naloxone\n oral naloxone n\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 2,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:30 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 108 (108 - 108) bpm\n BP: 125/70(82) {0/0(0) - 0/0(0)} mmHg\n RR: 38 (38 - 38) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4 mL\n PO:\n TF:\n IVF:\n 4 mL\n Blood products:\n Total out:\n 0 mL\n 650 mL\n Urine:\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -646 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 90%\n ABG: ////\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Oriented (to): person, place,\n time, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 633 K/uL\n 9.6 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 92 mEq/L\n 132 mEq/L\n 28.5 %\n 13.6 K/uL\n [image002.jpg]\n 05:09 AM\n WBC\n 13.6\n Hct\n 28.5\n Plt\n 633\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 104\n Other labs: PT / PTT / INR:14.6/28.2/1.3, CK / CKMB /\n Troponin-T:24//0.02, ALT / AST:27/39, Alk Phos / T Bili:157/0.3,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:7.0 %, Mono:6.0 %, Eos:9.0\n %, Albumin:2.6 g/dL, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Imaging: CXR : There has seen no interval change in the dilated\n tracheobronchial tree and dilated esophagus. The bibasilar\n consolidative changes of lung bases, which are superimposed on\n underlying interstitial lung disease, appear relatively unchanged.\n However, there are new foci of atelectasis within the right lung. No\n pneumothorax or pleural effusion is detected.\n .\n Chest CTA :\n 1. No pulmonary embolus.\n 2. Progressed interstitial lung disease including honeycombing,\n cylindrical\n bronchiectasis, and diffuse ground-glass opacification predominantly in\n the\n lower lobes. Nonspecific interstitial pneumonia is a primary diagnostic\n consideration, with the possibility of superimposed aspiration\n suggested\n particularly in light of the patulous esophagus. Although unlikely\n given age, connective tissue disease may also present in this manner.\n It would be atypical however to present at this advanced age.\n 3. Meidastinal adenopathy. Given relative dramatic sizes, felt out of\n proportion to be reactive nodes. Follow up CT in months recommended\n to\n further evaluate.\n 4. Large hiatal hernia with patulous esophagus. Contributes to\n possibility\n of superimposed aspiration.\n Microbiology: Rapid viral panel : negative\n Urine cx : GNRs\n Blood cx : NGTD\n Assessment and Plan\n 62M quadraparetic s/p transverse myelitis, sent to ICU from floor for\n hypoxia and closer monitoring/nursing care.\n .\n # Hypoxia: persistent despite antibiotics for presumed pneumonia,\n ?aspiration especially as patient has patulous esophagus. Concerning\n for underlying IPF given chest CT findings. Unable to bronch so far due\n to easy desaturation to 60s. No PE per chest CTA. Less likely is\n pulmonary edema. Leukocytosis improving on abx.\n - continue vanco, pip-tazo, levoflox for now\n - sputum cx\n - consider elective intubation for bronch\n - hold off on diuresis for now\n .\n # LE edema: Pt with notable LE edema which by report is new. Bilateral,\n with some erythema which could represent venous stasis vs cellulitis.\n Echo showed preserved biventricular systolic function. LENIS showed DVT\n in left femoral vein.\n - vanco will cover cellulitis\n - continue heparin gtt for now\n - gentle diuresis\n .\n # Sacral decubiti: Multiple sacral decubiti, with some ? osteo per\n wife. Was treated with levoflox as outpatient, scheduled for Plastics\n eval as outpatient..\n - f/u wound care recs\n - f/u plastics consult\n .\n # Tib/fib fx: Fx sustained falling from WC. This was not treated\n surgically.\n - Continue boot\n - Ortho prn\n .\n # Chronic pain: Pt is on several medications, including methadone and\n fenatyl.\n - Continue meds cautiously given resp status\n .\n # FEN: IVFs / replete lytes prn / NPO for now\n .\n # PPX: PPI, heparin gtt, bowel regimen\n .\n # ACCESS: PIV\n .\n # CODE: Full\n .\n # CONTACT: Wife\n .\n # DISPO: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2164-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369728, "text": "HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum\n" }, { "category": "Nursing", "chartdate": "2164-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369729, "text": "HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum\n Alteration in Nutrition\n Assessment:\n Pt remains on clear liquids because of poor resp status\n Action:\n Pt able to take pills with water,\n Response:\n No signs of aspiration\n Plan:\n They plan to put in a gi consult, ? if pt has silent aspiration when he\n sleeps, would keep pt on clears for the next 24 hrs as we watch is resp\n status\n Chronic Pain\n Assessment:\n Pt c/o generalized pain had not received his fent patch this am\n Action:\n Pt restarted on fent patch\n Response:\n Sleeping and comfortable\n Plan:\n Continue with fent patch and fent lolypops as needed, pt placed on\n kinair today and turned q2\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcers remain unchanged since last admission to the micu see metavison\n for discription\n Action:\n Dressings changed upon admission to the micu\n Response:\n Drainage noted yellow from L hip decub ? some order from area\n Plan:\n Will have wound care follow up on Monday , and will follow\n recommendations for care of decubs\n Hypoxemia\n Assessment:\n Pt arrived on 100% nrb, and 2L n/c sats 100%, lung sounds diminished\n thoughout\n Action:\n Have been able to wean pt to 50% shovel mask and 2l; n/c\n Response:\n Sats 94-97% on above settings, noted sats better when pt is placed L\n side down\n Plan:\n Nebs as ordered, turn and reposition q2, encourage pulm toilet,\n" }, { "category": "Nursing", "chartdate": "2164-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369730, "text": "HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum\n Alteration in Nutrition\n Assessment:\n Pt remains on clear liquids because of poor resp status\n Action:\n Pt able to take pills with water,\n Response:\n No signs of aspiration\n Plan:\n They plan to put in a gi consult, ? if pt has silent aspiration when he\n sleeps, would keep pt on clears for the next 24 hrs as we watch is resp\n status\n Chronic Pain\n Assessment:\n Pt c/o generalized pain had not received his fent patch this am\n Action:\n Pt restarted on fent patch\n Response:\n Sleeping and comfortable\n Plan:\n Continue with fent patch and fent lolypops as needed, pt placed on\n kinair today and turned q2\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcers remain unchanged since last admission to the micu see metavison\n for discription\n Action:\n Dressings changed upon admission to the micu\n Response:\n Drainage noted yellow from L hip decub ? some order from area\n Plan:\n Will have wound care follow up on Monday , and will follow\n recommendations for care of decubs\n Hypoxemia\n Assessment:\n Pt arrived on 100% nrb, and 2L n/c sats 100%, lung sounds diminished\n thoughout\n Action:\n Have been able to wean pt to 50% shovel mask and 2l; n/c\n Response:\n Sats 94-97% on above settings, noted sats better when pt is placed L\n side down\n Plan:\n Nebs as ordered, turn and reposition q2, encourage pulm toilet,\n" }, { "category": "Nursing", "chartdate": "2164-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 369731, "text": "HPI:\n 62M now readmitted to ICU for hypoxemic respiratory failure. Briefly,\n he was admitted earlier this week in the setting of relatively acute\n progression of dyspnea. He lives at home with his wife who helps take\n care of him, and approximately a week ago began to develop increased\n dyspnea. He has a history of asthma (but has not been prescribed\n prednisone in several years), and because of a history of pneumonias,\n he has home oxygen. He eventually put himself on oxygen but failed to\n improve. They spoke with his PCP, was concerned because of a\n recent femur fracture that his symptoms could be related to a pulmonary\n embolism, so he was sent to the ED. Here, he was initially found\n to be hypoxemic despite 4L O2, improved with NRB and was eventually\n admitted to the floor. His PE-CT was negative for PE, but did\n demonstrate bilateral lower lobe opacities. Following admission, his\n hypoxemia worsened and he was transferred to the ICU; where he improved\n back to requiring 4L NC. He was subsequently transferred back to the\n floor and pulmonary consult service was involved.\n I followed him from the consult service, and initial concern was for a\n possible aspiration event and possible development of aspiration PNA.\n However, he clinically continued to wax and wane in terms of his\n oxygenation. His radiiographs appeared largely unchanged despite\n intermittently requiring a NRB. Increasingly, we became more concerned\n about possible ILD or other inflammatory etiologies. So far,\n evaluation reveals a markedly elevated ESR and CRP; ANCA and IgE are\n still pending. Micro studies only consist of viral panel and\n legionella which are negative. The team has been unable to obtain\n sputum samples as he is not producing significant sputum\n Alteration in Nutrition\n Assessment:\n Pt remains on clear liquids because of poor resp status\n Action:\n Pt able to take pills with water,\n Response:\n No signs of aspiration\n Plan:\n They plan to put in a gi consult, ? if pt has silent aspiration when he\n sleeps, would keep pt on clears for the next 24 hrs as we watch is resp\n status\n Chronic Pain\n Assessment:\n Pt c/o generalized pain had not received his fent patch this am\n Action:\n Pt restarted on fent patch\n Response:\n Sleeping and comfortable\n Plan:\n Continue with fent patch and fent lolypops as needed, pt placed on\n kinair today and turned q2\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcers remain unchanged since last admission to the micu see metavison\n for discription\n Action:\n Dressings changed upon admission to the micu\n Response:\n Drainage noted yellow from L hip decub ? some order from area\n Plan:\n Will have wound care follow up on Monday , and will follow\n recommendations for care of decubs\n Hypoxemia\n Assessment:\n Pt arrived on 100% nrb, and 2L n/c sats 100%, lung sounds diminished\n thoughout\n Action:\n Have been able to wean pt to 50% shovel mask and 2l; n/c\n Response:\n Sats 94-97% on above settings, noted sats better when pt is placed L\n side down\n Plan:\n Nebs as ordered, turn and reposition q2, encourage pulm toilet,\n .H/O anxiety\n Assessment:\n Pt very anxious upon admission wanting his brother or wife to come in,\n difficulty getting pt to calm down, pt asking for xanax for anxiety\n Action:\n Pt given ,25mh po x1 at 1300\n Response:\n Pt fell asleep but very somulent several hr later, wife stated that he\n usually takes half a dose\n Plan:\n Would try .125 if pt needs more xanax, he has a hx of anxiety and wife\n states it gets worse when he is ill\n Pt on heparin drip at 2000U hr, repeat ptt 50 at 1500, dripp ^ to 2100U\n at 1700 and was bolus with 1200U prior, next ptt due in 6 hrs\n" }, { "category": "Radiology", "chartdate": "2164-02-15 00:00:00.000", "description": "R KNEE (AP, LAT & OBLIQUE) RIGHT", "row_id": 1068472, "text": " 5:49 PM\n KNEE (AP, LAT & OBLIQUE) RIGHT; TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: h/o prior fracture, interval healing;\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with h/o right tib/fib fracture, last film at \n REASON FOR THIS EXAMINATION:\n h/o prior fracture, interval healing;\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture.\n\n Four radiographs of the right knee and leg are submitted.\n\n There is a displaced and angulated fracture involving the tibial plateau.\n There is associated sclerosis about the tibial fracture. Similarly, there is\n a nondisplaced fracture of the proximal metadiaphysis of the right fibula.\n Assessment for knee joint effusion is markedly limited by patient positioning,\n none is identified. There is equivocal evidence of sclerosis about the\n tibiotalar joint and the lateral malleolus, not well assessed at edge the of\n the imaged field of view. There is likely remote trauma of the medial\n malleolus. The talar dome contour is smooth.\n\n IMPRESSION:\n\n Angulated and minimally displaced fractures involving the proximal metaphyses\n of the tibia and fibula.\n\n Probable remote trauma about the right ankle, not well assessed on these knee\n and leg radiographs. If clinically indicated, further assessment could be\n obtained with routine right ankle radiographs.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1068548, "text": " 9:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with shortness of breath.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:26 AM\n 1. Progressive, confluent airspace process superimposed on underlying severe\n interstitial pulmonary fibrosis, suggestive of worsening aspiration\n pneumonitis.\n 2. No specific evidence of volume overload/CHF.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, \n\n HISTORY: 62-year-old man with shortness of breath; assess for interval\n change.\n\n FINDINGS: Single bedside AP examination labels \"upright at 10:00 a.m.\" is\n compared with supine examination of , remote study, as well as\n recent chest CTA of . There is marked dilatation of the\n thoracic trachea and mainstem bronchi, as before. There is diffuse, coarse\n both alveolar and interstitial opacity involving both lung bases and the right\n mid-lung, where it appears more confluent since the most recent study. This\n likely corresponds to an acute pneumonic process, perhaps related to\n aspiration, superimposed on the extensive interstitial fibrosis, particularly\n at the bases, demonstrated by recent CT. There is no significant change in\n heart size or development of pleural effusion or vascular congestion to\n specifically suggest component of CHF/volume overload. The previously gas-\n distended esophagus may now be fluid-filled, though there is continued gaseous\n distention of bowel loops in the left upper abdomen.\n\n IMPRESSION:\n 1. Progressive, confluent airspace process superimposed on underlying severe\n interstitial pulmonary fibrosis, suggestive of worsening aspiration\n pneumonitis.\n 2. No specific evidence of volume overload/CHF.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1068549, "text": ", C. MED CC7A 9:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with shortness of breath.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n PFI REPORT\n 1. Progressive, confluent airspace process superimposed on underlying severe\n interstitial pulmonary fibrosis, suggestive of worsening aspiration\n pneumonitis.\n 2. No specific evidence of volume overload/CHF.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1069054, "text": " 3:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/o PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with oxygen requirement, leukocytosis\n REASON FOR THIS EXAMINATION:\n e/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Oxygen requirement, history of pneumonia.\n\n FINDINGS:\n\n There is little appreciable change since the prior study of . There is\n continued patchy airspace opacification of the right lung and left lower lobe.\n These findings are consistent with multilobar pneumonia. These findings\n appear to be superimposed on underlying interstitial disease.\n Cardiomediastinal silhouette is unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1069355, "text": " 11:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with ? pneumonia, on steroids\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible pneumonia on steroids, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is little interval\n change. Again there is striking dilatation of the tracheobronchial tree.\n Bibasilar areas of opacification persist, consistent with consolidation\n superimposed upon underlying interstitial lung disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-14 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1068267, "text": " 2:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with dyspnea and recent leg fx, d dimer 7000\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp TUE 4:21 PM\n\n No central PE\n Bibasal GGO and more consolidative opc w/enlarged subcarinal ? pna\n\n Interstitial lung dz wide diff - pending chest rad consult\n WET READ VERSION #1 GWp TUE 3:33 PM\n No central PE\n Bibasal GGO and more consolidative opc w/enlarged subcarinal ? pna\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 62-year-old man with dyspnea and recent leg fracture, evaluate\n for PE.\n\n COMPARISON: .\n\n TECHNIQUE: Multiple MDCT axial images were obtained from the base of the\n lungs through the upper abdomen after the administration of 100 mL of Optiray\n intravenously. reformations were derived.\n\n FINDINGS:\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST:\n\n There is no pulmonary embolus. The main pulmonary artery measures to 2.8 cm.\n There are prevascular nodes (6:15), An AP window node measures 1.8 x 1.1 cm\n (6:12), a precarinal node measures 2.2 x 2.8 mm (6:21), and subcarinal nodes\n measure to 2.5 x 2.1 cm (6:32).\n\n The trachea more expanded (6:8) suggestive of increased lung volume loss and\n trachemmalacia. Airways are patent to the level of subsegmental bronchi.\n There is progressed and now severe cylindrical bronchiectasis compared with\n the study of . A right hilar mass (6:40) measuring 2.2 x 3.6\n cm is likely an enlarged hilar node, although neoplasm cannot be ruled out.\n Anteriorly in the lingula and right middle lobe, there is honeycombing (6:32).\n In a predominantly lower lobe distribution, there is diffuse, patchy ground-\n glass opacification. A patulous fluid-filled esophagus is noted.\n\n The heart appears top normal in size. There is no pericardial effusion. There\n is no aortic dissection. Atherosclerotic change including vascular\n calcification is seen in the aorta. The aorta is normal in caliber measuring\n 2.7cm 1cm superior to the sinotubular ridge, 2.2cm at the aortic arch and\n 1.9cm at the diaphragmatic aperture.\n (Over)\n\n 2:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n In the visualized abdomen, there is a large hiatal hernia. The visualized\n portion of the spleen and liver are grossly unremarkable.\n\n IMPRESSION:\n\n 1. No pulmonary embolus.\n\n 2. Progressed interstitial lung disease including honeycombing, cylindrical\n bronchiectasis, and diffuse ground-glass opacification predominantly in the\n lower lobes. Nonspecific interstitial pneumonia is a primary diagnostic\n consideration, with the possibility of superimposed aspiration suggested\n particularly in light of the patulous esophagus. Although unlikely given age,\n connective tissue disease may also present in this manner. It would be\n atypical however to present at this advanced age.\n\n 3. Meidastinal adenopathy. Given relative dramatic sizes, felt out of\n proportion to be reactive nodes. Follow up CT in months recommended to\n further evaluate.\n\n 4. Large hiatal hernia with patulous esophagus. Contributes to possibility\n of superimposed aspiration.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-15 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1068372, "text": " 8:04 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BILAT. LE SWELLING, EVAL. FOR DVT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with new LE edema, tib/fib fx on R\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf WED 9:29 AM\n Limited study due to splint. DVT in left proximal and mid femoral vein. Dr.\n paged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old man with new lower extremity edema. Evaluate for DVT.\n\n TECHNIQUE: Bilateral lower extremity venous study.\n\n FINDINGS: Study was limited due to placement of a splint on the right\n extremity, and chronic positioning of the left extremity.\n\n On the right side, Grayscale and Doppler son of the right common femoral\n vein, greater saphenous vein, and proximal and mid superficial femoral vein\n were performed. There was normal compressibility, flow, and augmentation.\n\n In the left extremity, due to positioning of the left extremity, the study was\n limited and was only able to assess the left common femoral vein, left\n greater saphenous vein, and proximal and mid portion of superior femoral vein\n (which is considered a deep vein), and popliteal vein. The distal portion of\n superior femoral vein was difficult to assess. The popliteal vein was\n assessed. There is thrombosis in the proximal and mid portion of the superior\n femoral vein (please note superficial femoral vein is considered a deep vein).\n Popliteal vein on the left is patent, with no evidence of thrombosis.\n\n IMPRESSION: Limited study. Deep venous thrombosis in the left proximal and\n mid femoral vein.\n\n Results were discussed with Dr. at that time scan was done.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-15 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1068373, "text": ", C. MED MICU-7 8:04 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BILAT. LE SWELLING, EVAL. FOR DVT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with new LE edema, tib/fib fx on R\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n Limited study due to splint. DVT in left proximal and mid femoral vein. Dr.\n paged.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1068348, "text": " 3:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with pna\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with pneumonia.\n\n Comparison is made to the prior CT of the chest of and CT of\n the torso of .\n\n Findings: The heart size is normal. The mediastinal contour is normal. The\n tracheobronchial tree is moderately to severely distended. The esophagus is\n also moderately distended. No focal consolidation visualized. No pulmonary\n vascular congestion is noted. Patient demonstrates ground glass opacities and\n fibrosis at the lung bases. Findings are mostly concerning for fibrotic\n process with superimposed aspiration which appears unchanged compared to the\n recent CT.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1068721, "text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Concern for mucous plugging or aspiration event\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hypoxia.\n REASON FOR THIS EXAMINATION:\n Concern for mucous plugging or aspiration event\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr FRI 2:36 PM\n PFI: There has seen no interval change in the dilated tracheobronchial tree\n and dilated esophagus. The bibasilar consolidative changes of both lung\n bases, which are superimposed on underlying interstitial lung disease, appear\n relatively unchanged. However, there are new foci of atelectasis within the\n right line. No pneumothorax or pleural effusion is detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with hypoxia.\n\n Comparison is made to the prior study of .\n\n PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: There has seen no interval\n change in the dilated tracheobronchial tree and dilated esophagus. The\n bibasilar consolidative changes of lung bases, which are superimposed on\n underlying interstitial lung disease, appear relatively unchanged. However,\n there are new foci of atelectasis within the right lung. No pneumothorax or\n pleural effusion is detected.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1068722, "text": ", H. MED CC7A 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Concern for mucous plugging or aspiration event\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hypoxia.\n REASON FOR THIS EXAMINATION:\n Concern for mucous plugging or aspiration event\n ______________________________________________________________________________\n PFI REPORT\n PFI: There has seen no interval change in the dilated tracheobronchial tree\n and dilated esophagus. The bibasilar consolidative changes of both lung\n bases, which are superimposed on underlying interstitial lung disease, appear\n relatively unchanged. However, there are new foci of atelectasis within the\n right line. No pneumothorax or pleural effusion is detected.\n\n" }, { "category": "ECG", "chartdate": "2164-02-14 00:00:00.000", "description": "Report", "row_id": 159587, "text": "Baseline artifact. Sinus tachycardia. Consider ST-T wave abnormalities.\nSince the previous tracing of the rate is faster. Artifact is more\nprominent. Clinical correlation is suggested.\n\n" } ]

[ { "category": "ECG", "chartdate": "2152-09-19 00:00:00.000", "description": "Report", "row_id": 193363, "text": "Sinus tachycardia. Otherwise, the findings are within normal limits. Compared\nto the previous tracing of there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2152-09-15 00:00:00.000", "description": "Report", "row_id": 193364, "text": "Sinus rhythm with borderline prolongation of P-R interval. Compared to the\nprevious tracing of the rate is increased slightly. The other findings\nare similar.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1251813, "text": " 11:47 AM\n CHEST (PA & LAT) Clip # \n Reason: pneumonia\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with recent knee replacement and gout of right wrist is now\n febrile.\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n Recent knee replacement, now febrile.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The left costophrenic sinus is obliterated by a combination of small\n effusion and atelectasis. No newly occurred parenchymal opacities. Unchanged\n borderline size of the cardiac silhouette without pulmonary edema. No\n right-sided pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251564, "text": " 11:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question of pneumonia.\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with fever after recent knee surgery.\n REASON FOR THIS EXAMINATION:\n question of pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male with fever after recent knee surgery.\n\n COMPARISON: Comparison is made with chest radiograph from .\n\n FINDINGS: Single frontal image of the chest demonstrates new opacity at the\n left lateral lung base which could be consistent with fluid and/or\n atelectasis. It is difficult to assess this opacity fully given the patient's\n extremely rotated position. Lungs are otherwise clear. There is no\n pneumothorax. Cardiomediastinal silhouette is unchanged from prior imaging.\n\n IMPRESSION: New left lateral lung base opacity consistent with pleural\n effusion and/or atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-09-15 00:00:00.000", "description": "L KNEE (2 VIEWS) LEFT", "row_id": 1251025, "text": " 9:25 AM\n KNEE (2 VIEWS) LEFT Clip # \n Reason: post op eval\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p revision L TKA\n REASON FOR THIS EXAMINATION:\n post op eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male status post revision of the left knee total\n arthroplasty.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the left knee demonstrate interval\n placement of a constrained total knee arthroplasty with femoral and tibial\n components closely adherent to the bony surfaces and the tibial component\n reinforced by bone graft material. There is no evidence of hardware failure\n or loosening. There is overlying surgical staples along the anterior knee. A\n large suprapatellar effusion is likely present, in keeping with postoperative\n state. No fracture or dislocation.\n\n IMPRESSION: Interval placement of constrained total knee arthroplasty.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1252103, "text": " 9:55 AM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: new 44cm SL L basilic PICC placed - \n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with new L PICC\n REASON FOR THIS EXAMINATION:\n new 44cm SL L basilic PICC placed - \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male with new PICC line.\n\n COMPARISON: Comparison is made with chest radiographs from .\n\n FINDINGS: Left-sided PICC line can be traced as far as the junction of the\n brachiocephalic veins, beyond which it is not visible. There is no\n pneumothorax or other complication. The lungs are well expanded. Pulmonary\n vascular congestion has improved since prior exam. Persistent left-sided\n opacity is likely atelectasis. There is a small left pleural effusion. There\n is no right pleural effusion. The right lung is clear. Mild cardiomegaly is\n stable.\n\n IMPRESSION: Left-sided PICC line with tip in unclear location. Persistent\n left basilar atelectasis and small left pleural effusion.\n\n Wet read originally stated that the left PICC line tip was 4 cm distal to the\n brachiocephalic/SVC junction and that the catheter needed to be advanced 6 cm.\n This wet read was communicated to with the IV nursing team at 10:22\n a.m. by telephone.\n\n Final read with the impression as above was communicated to the IV nursing\n team at 12:15 p.m. at the time of the patient's subsequent chest radiograph\n wet read, at which time a PA and lateral was recommended.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251048, "text": " 11:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Infiltrate?\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69/M s/p L TKA POD 2, T101.1 yesterday evening -> UA wnl. Tcurr 102.3, WBC\n 13.2. assess for infiltrate.\n REASON FOR THIS EXAMINATION:\n Infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male, status post total knee arthroplasty, postop day\n 2, now with fever and increasing white blood cell count.\n\n COMPARISON: Comparison is made with chest radiographs from and\n .\n\n FINDINGS: Single frontal image of the chest was obtained. There are low lung\n volumes, likley due to poor inspiration. There are bilateral pleural\n effusions, left greater than right, which appear new since prior exam. There\n is no pneumothorax. Cardiomegaly is again seen. Cardiomediastinal silhouette\n is unchanged.\n\n IMPRESSION: New pleural effusions, left greater than right.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-17 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1251228, "text": " 2:15 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ? RUE thrombus\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with right forearm swelling and pain.\n REASON FOR THIS EXAMINATION:\n ? RUE thrombus\n ______________________________________________________________________________\n WET READ: SUN 3:38 PM\n No evidence of right upper extremity DVT, although right axillary vein could\n not be imaged as the patient could not tolerate the necessary positioning to\n interrogate this vessel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right forearm swelling and pain. Evaluate for right upper\n extremity DVT.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color son were acquired of the right internal\n jugular, subclavian, axillary, brachial, basilic, and cephalic veins. There\n is normal compressibility, flow, and augmentation throughout all imaged veins,\n although the axillary vein could only be assessed with compression given\n limitations in patient mobility of the right upper extremity.\n\n IMPRESSION: No evidence of DVT in the right upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1252119, "text": " 11:51 AM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : exchange - 52cm SL L basilic PICC - \n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with PICC exchange\n REASON FOR THIS EXAMINATION:\n exchange - 52cm SL L basilic PICC - \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: New PICC line.\n\n COMPARISON: .\n\n FINDINGS:\n\n The patient is rotated towards the left side and the end of left-sided PICC\n line not clearly seen. This has been discussed with IV nurse, \n and PA and lateral chest x-ray had been suggested.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-19 00:00:00.000", "description": "R US INTERMED JOINT ASP/INJECT RIGHT", "row_id": 1251411, "text": " 8:08 AM\n US INTERMED JOINT ASP/INJECT RIGHT; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: Aspiration of right wrist. Question septic arthritis vs.crys\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ********************************* CPT Codes ********************************\n * US INTERMED JOINT ASP/INJECT RIGHT GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man who presented for knee replacement complicated by fevers,\n delirium and significant right wrist pain.\n REASON FOR THIS EXAMINATION:\n Aspiration of right wrist. Question septic arthritis vs.crystal arthritis.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal insufficiency\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Ultrasound-guided aspiration of right wrist joint.\n\n CLINICAL INDICATION: 69-year-old man with remote history of gout (treated\n medically), presenting with wrist pain, swelling, erythema, and low-grade\n fevers. Concern for infection versus inflammatory gout.\n\n COMPARISON: Radiographs from .\n\n TECHNIQUE: After risks, benefits, and alternatives were explained to the\n patient, written informed consent was obtained. Prior to the procedure, a\n timeout was performed with three patient identifiers. The patient was placed\n supine on the ultrasound bed and diagnostic -scale and color Doppler\n images of the right were obtained.\n\n A suitable approach to the right wrist joint was obtained (along the dorsal\n aspect of the radiocarpal joint). Site was identified and mark placed on skin\n for approach. 1% lidocaine was used to anesthetize the skin and subcutaneous\n tissues. Under fluoroscopic guidance, a 19-gauge needle was advanced towards\n the dorsal right radiocarpal joint. Subsequently, approximately 1.5 mL of\n whitish/creamy/purulent fluid was aspirated from the joint. The needle was\n removed, and hemostasis achieved, and sterile dry gauze dressing applied.\n\n The patient tolerated the procedure well, and there were no immediate\n complications.\n\n FINDINGS: -scale and color Doppler static images demonstrated\n subcutaneous/soft tissue swelling and edema. There was a thick laminar layer\n of fluid at the radiocarpal joint. Evaluation of the soft tissue demonstrated\n prominent cutaneous veins. These veins were followed proximally with no\n evidence of thrombosis or obstructing mass.\n\n\n IMPRESSION:\n 1. Successful ultrasound-guided aspiration of 1.5 mL of\n creamy/whitish/purulent fluid from the patient's right radiocarpal joint.\n Specimens were obtained and carried to the pathology lab for cell count and\n (Over)\n\n 8:08 AM\n US INTERMED JOINT ASP/INJECT RIGHT; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: Aspiration of right wrist. Question septic arthritis vs.crys\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n differential, culture and sensitivity, and crystal analysis.\n\n 2. Thick laminar right wrist joint fluid was evaluated, and aspirated as\n described above. Diffuse soft tissue edema and swelling is noted.\n\n Dr. , the attending radiologist, was present for and\n supervised the entire procedure.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1252130, "text": " 1:44 PM\n CHEST (PA & LAT) Clip # \n Reason: eval picc location\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with picc placement. Eval site of picc.\n REASON FOR THIS EXAMINATION:\n eval picc location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male with PICC line placement.\n\n COMPARISON: Comparison is made with chest radiograph from earlier the same\n day and .\n\n FINDINGS: PA and lateral images of the chest demonstrate a left-sided PICC\n line with the tip in the right atrium. The tip needs to be pulled back 4 cm\n to be in appropriate position. There is no pneumothorax or other complication\n seen. The lungs are well expanded. Again seen is a left lower base opacity\n consistent with atelectasis and a small left pleural effusion. The chest\n radiograph is otherwise unchanged from imaging earlier the same day.\n\n IMPRESSION: Left PICC line with tip in the right atrium. Catheter needs to\n be pulled back 4 cm to be in appropriate position.\n\n These findings were communicated to with the IV nursing team at 2:07\n p.m. by telephone.\n\n" }, { "category": "Radiology", "chartdate": "2152-09-16 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 1251148, "text": " 1:50 PM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: ? fx\n Admitting Diagnosis: LEFT KNEE FAILED TOTAL KNEE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with diffuse right wrist pain\n REASON FOR THIS EXAMINATION:\n ? fx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Diffuse right wrist pain. Evaluate for fracture.\n\n RIGHT WRIST:\n\n Extensive degenerative changes are present within the right wrist. It is\n maximal at the radial-carpal junction. There is, however, no evidence of a\n fracture present.\n\n IMPRESSION: Degenerative changes within the carpal bones.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2185-06-12 00:00:00.000", "description": "Report", "row_id": 269216, "text": "Sinus rhythm, rate 66. Since the previous tracing of T waves are more\ninverted in leads I and aVL. Some flattening of the T waves are seen over the\nmid-lateral precordium.\n\n" }, { "category": "Radiology", "chartdate": "2185-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911993, "text": " 4:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check trach placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39year old man with Prader Willi now s/p tracheostomy\n\n REASON FOR THIS EXAMINATION:\n check trach placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check position post-tracheostomy.\n\n COMPARISON: .\n\n FINDINGS: A tracheostomy overlies the trachea 5 cm above the carina at the\n level of the clavicles. No pneumothoraces are present. Otherwise the study\n is unchanged with significant bilateral airspace opacities. Spine hardware is\n also present. Left subclavian central line is unchanged in position.\n\n IMPRESSION: Successful tracheostomy.\n\n" }, { "category": "Radiology", "chartdate": "2185-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911832, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate lines/tubes/interval changes\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39year old man with Prader Willi and OSA intubatede\n REASON FOR THIS EXAMINATION:\n evaluate lines/tubes/interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 04:34.\n\n INDICATION: Check lines and tubes.\n\n COMPARISON: at 14:37.\n\n FINDINGS: Compared to the film of , there is no significant interval\n change in the lungs, showing lung volumes and bilateral airspace opacities.\n The tip of the left CVL was seen in the SVC and there is no PTX. The tip of\n the ETT remains overlying the T2 vertebral body.\n\n IMPRESSION:\n\n No significant interval change versus prior.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2178-04-30 00:00:00.000", "description": "Report", "row_id": 1560943, "text": "MICU Admission Note 0000-0700\nPt is a 70 yo white male admitted via ER to MICU-688 from hospital with DKA and Right Subdural Hematoma s/p fall at home. Pt presented to OSH with c/o cold symptoms/weakness/dizziness/ falls every day for past week---admitted for workup and transferred to for further management of subdural hematoma and DKA. Other PMH sig. for DM (oral ) and high cholesterol, s/p rotator cuff repair, and nasal surgery in past. Meds PTA include glucophage and lipitor. Pt lives alone with his cat, he is divorced and has 2 sons that reside in , his brother found him to be weak and confused and brought him to OSH with above symptoms. At OSH pt with CPK= 1716 but neg. troponin, diffuse ecchymotic area over right flank extending to middle of back due to fall at home, c-spine \"cleared\" at OSH, CXR and Abd CT reported as neg. at OSH. Arrived in ED in DKA with glu > 500 and + gap with Co2=10---placed on insulin gtt at that time. Repeat Head CT reported as New moderate sized Right Subdural Hematoma and chronic Left subdural hematoma. Neuro and NeuroSurg following. Cspine CT revealed possible anterior ligamentous injury---new collar placed on pt at present time as trauma MD.\n\nNeuro: Alert and oriented X 3---somewhat confused as to date. Denies H/A, denies dizziness or lightheadedness, c/o mild discomfort when turns onto right side due to severely bruised flank, Pupils = 4 mm and brisk, equal strength in all extremities, follows commands, localizes to pain, cooperative and appropriate, slightly slurred speech, smile symmetrical and tongue midline, ? of slight facial droop on right after collar placed back on pt's neck?? No seizure activity noted, Loaded with 1 gm. IV Dilantin and to start po today. C/O numbness in right hand and right fingertips---states he had it yesterday but it went away and now it's back---MICU HO assessed.\n\nCardiac: HR= 79-91 SR with occasional PAC's, no PVC's noted, BP= 137-151/50-60's, CPK= 1379 in ED and now down to 859 this am. Troponin remains neg. EKG obtained and revealed ST depression--MICU resident aware and assessed. Denies CP. Arrived with (2) PIV's----(1) #20ga.left hand and (1)#18 Left AC. IV NS at 200ml/hr and IV D5 1/2NS at 80 ml/hr D/C'd and IV D5NS with 40 mEq KCL infusing at 200ml/hr. K= 3.0 this am---pt received 40 mEq po KCl x 1 dose and is receiving 40 mEq in IVF at present time. Na= 128 in ED and now 132.\n\nResp: Lungs clear to bilat. bases. Nonproductive cough noted. 02 at 2L NC with Sats= 97-99%. Denies SOB.\n\nEndo: Arrived to MICU on IV Insulin gtt infusing at 3 units/hr with fingerstick on arrival = 236....insulin titrated up hourly and currently receiving 8 units/hr with last fingestick= 147. CO2 increased from 10 to 21 and gap now closed.\n\nID: WBC in ED= 19.2----arrived with low grade temp= 99.2\n Repeat WBC this am= 12.2 and pt currently afebrile. No antibx.\n Blood Cx. sent X 1\n\nGI: Abd soft with + bowel sounds all quads. NPO except meds maintained.\n" }, { "category": "Nursing/other", "chartdate": "2178-04-30 00:00:00.000", "description": "Report", "row_id": 1560944, "text": "MICU Admission Note 0000-0700\n(Continued)\n Asp. precautions maintained. No BM.\n\nGU: Foley to CD draining clear amber urine. U/O= 35-50 ml/hr. UA and C/S sent.\n\nSkin: Pt with large hematoma over right flank and extending around to mid back---purple and soft, tender. Area marked and unchanged since admission. Small ecchymotic areas over right shoulder area also marked and unchanged. Abrasion on right knee and elbow with scab formation and unchanged. HCT= 34.9---down from 39.9 in ED.\n\nSocial: No contact from family and friends during night. Pt advises that his brother() and his 2 sisters and ) are aware that he is here at . Contact number for is on board in room but pt wants his brother to be first contact but can't remember his number---will need to obtain this today. Pt advises that he has 2 sons that reside in and they are unaware of his condition. Pt's wallet sent to security and locked up.\n\nPlan: Will repeat Head CT and C-spine today, CXR PA and LAT today, Continue with Q1 hour neuro checks and Q1 hour fingersticks, Titrate insulin gtt to fingersticks 80-120, NPO, r/o MI, replace electrolytes prn, Check Dilantin level, Freq. check of Hct, Monitor flank hematoma for extension, Social Service consult for possible d/c planning needs and contact information ( HCP), Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2178-04-30 00:00:00.000", "description": "Report", "row_id": 1560945, "text": "MICU 6 NURSING PROGRESS NOTE 0700-1900\nNEURO--ALERT AND ORIENTED X2-3 WITH FORGETFULNESS ON NAME OF HOSPITAL AND OCCASIONALLY YEAR. MAE SPONT. FOLLOWS SIMPLE COMMANDS CONSISTENTLY. SPEECH IS MOSTLY CLEAR BUT WHEN AROUSES FROM SLEEP IT IS MORE SLURRED. PEARL AT 4-5MM. TONGUE MIDLINE. SMALL RUE DRIFT AWAY FROM MIDLINE WHEN ARMS ARE EXTENDED OUTWARD AND PT IS FLAT IN BED.\n\nCARDIAC--LYTES REPLETED. PHOS VERY LOW AND RECEIVING KPHOS. HR 80'S SR WITH OCCASIONAL APC'S AND UNIFOCAL PVC'S.THEY ARE RESOLVING WITH REPLETION OF LYTES. MAP >70.\n\nRESP--SPONT RESP 16-24. R/A SAO2 >97%. THIS AM, R SIDE WITH INSP/EXP WHEEZE. THIS HAS CLEARED BUT BILAT. LOWER LOBES ARE DIMINISHED. STRONG PRODUCTIVE COUGH OF THICK TAN SPUTUM.\n\nGI--DIET CHANGED TO . TAKING WATER WITHOUT PROBLEMS. WILL GIVE DIET JELLO LATER. +BS. NO STOOL.\n\nGU--UO >50CC HR OF YELLOW SEDIMENT URINE, YEASTY APPEARANCE VIA FOLEY CATH.\n\nENDO--REMAINS ON INSULIN GTT WHICH WILL BE TURNED OFF AT 1600 AS PT 10 U NPH INSULIN SC AT 1400. BS IS CONTROLLED AT THIS TIME WITH LAST BS OF 111. NA+ INCREASING, K+WNL, PHOS AND CA++LOW.\n\nSKIN--LGR HEMATOMA ON R FLANK. IT HAS NOT INCREASED IN SIZE FROM PRIOR MARKINGS ON SKIN. PT HAS 3 AREAS THE SIZE OF A NICKEL ON R BUTTOCKS CLEAVAGE INTO GLUTEAL FOLD. IT IS TO DERMIS. AREA CLEANSED WITH SOAP AND H2O AND DUODERM APPLIED. GIVEN PT'S LGR CPK AND DECUBITI THERE IS A QUESTION OF WHETHER PT WAS \"DOWN\" FOR AWHILE BEFORE BEING FOUND. NO OTHER EVIDENCE TO SUPPORT THIS AT THIS TIME. ORAL CAVITY DRY. EXTREMITIES COOL AND PALE. COLLAR CARE GIVEN. NECK INTACT.\n\nID--AFEBRILE. NOT ON ABX. SPUTUM APPEARS INFECTED.\n\nPAIN--DENIES ANY PAIN. NO PAIN MED GIVEN.\n\n PT'S SISTER HAS PHONED AND HAS BEEN UPDATED REGARDING PT'S NIGHT AND CONDITION. PT HAS 2 SONS WHO LIVE IN THE . SON PHONED TO FIND OUT ABOUT FATHER'S CONDITION. THIS RN ASKED WHEN HE LAST SAW HIS FATHER AND HE RESPONDED THAT HE HASN'T SEEN HIS DAD IN 3 . HE STATES THAT HE HAS SPOKEN WITH HIS DAD \"ABOUT 3 WKS AGO\".\nTHIS RN ASKED PT IF HE WANTED TO SPEAK WITH HIS SON AND HE SAID YES. THE CONVERSATION WAS SHORT BUT SOUNDED LOVING AS PT SAID ,\"I LOVE YOU TOO.\" SON HAS SINCE CALLED X2.\n\nRADIOLOGY- DOWN FOR HEAD CT AND EXT/FLEXION FILMS OF C-SPINE. HE REMAINS IN COLLAR UNTIL FINAL REPORT.\n\nA--LESS ALERT AS DAY IS PROGRESSING. REMAINS ORIENTED BUT LETHARGIC.\n\nP--CON'T TO REDIRECT AND REORIENT AS NEEDED. CHECK LYTES LATER. TURN OFF INSULIN GTT AT 1600. CHECK BS AT 1800. OFFER SUPPORT TO PT .\n\n" }, { "category": "Nursing/other", "chartdate": "2178-05-01 00:00:00.000", "description": "Report", "row_id": 1560946, "text": "MICU Nursing Note 1900-0700\nEvents: Pt remains lethargic but easily arouseable and oriented. No seizure activity noted. Hemodynamically stable at present time. Febrile with Tmax of 102.5---blood cultures sent.\n\nNeuro: Lethargic but easily arouseable. Orientation waxing and ---at times pt oriented X3 and other times pt has difficulty with place and date. Slow recall. Moving all extremities and equal strength and grips in all extremities, Pleasant and cooperative and follows all commands, PEARl===4 mm., C/O numbness in right hand and fingers, Denies dizziness, Denies H/A, No N/V, J collar remains in place. No seizure activity noted. Continues on PO Dilantin. Dilantin level = 18.1 last eve.\n\nCardiac: HR= 80-90's SR with no ectopy noted, BP= 101-122/50's, Denies CP. IV NS infusing at KVO.\n\nResp: Lungs with coarse sounds upper airways with nonprod. cough noted during night. RA Sats= 95-99%. Denies SOB.\n\nGI: Taking liquids during night with asp. precautions, Abd. soft with + bowel sounds. No BM. No Flatus.\n\nEndo: Fingersticks 120-220's. Being covered with NPH insulin and sliding scale regular insulin.\n\nID: Fever spike to 102.5 this am. Blood cultures sent. CXR reported as RLL pna. WBC this am= 7.4. Started on IV Ceftriaxone and PO Azithromycin. Tylenol X 2 with good effect.\n\nGU: Foley to CD draining clear yellow urine 35-100ml/hr.\n\nSkin: Ecchymotic areas over right flank remains purple---slight extension to posterior left flank and over right ribs---areas marked. Duoderm intact on buttocks. HCT stable at 29.3 this am (was 28.8)\n\nSocial: No contact from family or friends during night.\n\nPlan: Continue Q1 hour Neuro checks, Obtain Clarification of C spine status in attempt to define status of J collar, Replace electrolytes as ordered, Pulmonary Toiletting, Freq. safety checks, Monitor hematoma over flank, Encourage diet as tolerated, Support pt and family.\n" }, { "category": "ECG", "chartdate": "2178-04-30 00:00:00.000", "description": "Report", "row_id": 199808, "text": "Probable ectopic atrial rhythm, although consider also accelerated junctional\nrhythm. Left ventricular hypertrophy with ST-T wave abnormalities. The\nST-T wave changes are diffuse. Clinical correlation is suggested. Since the\nprevious tracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2178-04-29 00:00:00.000", "description": "Report", "row_id": 199809, "text": "Probable ectopic atrial rhythm, although consider also, accelerated junctional\nrhythm. Left bundle-branch block with ST-T wave abnormalities. The ST-T wave\nchanges are diffuse. Clinical correlation is suggested. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2178-04-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 911472, "text": " 8:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for interval change in size of subdural\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p multiple falls from standing with subdural hematoma.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change in size of subdural\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN .\n\n INDICATION: 7-year-old male with multiple falls, evaluate for change in\n subdural hematoma.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n Comparison is made to the previous study of .\n\n FINDINGS:\n The right and left subdural hematomas are not appreciably changed in size or\n distribution. There is no change in the associated mass effect. The\n appearance of the brain is stable, with no areas of edema or parenchymal\n hemorrhage identified. The ventricles are not dilated.\n\n IMPRESSION: Stable appearance of the brain and subdural hematomas, compared\n to the previous study of . Dr. was informed of these\n findings at 9:52 a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2178-05-09 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 912686, "text": " 1:05 AM\n MR CERVICAL SPINE Clip # \n Reason: ?fx of ligamentus or disc injury\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with s/p fall and new R SDH.\n REASON FOR THIS EXAMINATION:\n ?fx of ligamentus or disc injury\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the cervical spine.\n\n CLINICAL INFORMATION: Patient is status post fall and new right-sided\n subdural hematoma, question fracture or ligamentous injury in the cervical\n spine.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 and gradient echo\n axial images of the cervical spine were acquired. Correlation was made with\n the cervical spine CT of .\n\n FINDINGS: At the craniocervical junction and C2-3 and C3-4, mild degenerative\n changes are noted.\n\n At C4-5, mild bulging is seen without foraminal stenosis.\n\n At C5-6, disc and uncovertebral degenerative changes are noted with moderate-\n to-severe right foraminal stenosis. Mild bulging is seen.\n\n At C6-7, disc and uncovertebral degenerative changes are noted with mild-to-\n moderate left foraminal stenosis.\n\n At C7-T1, there is mild anterolisthesis of C7 over T1 secondary to\n degenerative change.\n\n From T1-2 to T3-4 degenerative changes are identified.\n\n There is no evidence of abnormal signal seen within the ligamentous structures\n to indicate disruption. Facet joint alignment is normal. Abnormally\n increased signal is seen within the left facet joint at C3-4 level with fluid\n which could be secondary to degenerative change.\n\n There is no evidence of abnormal signal seen within the spinal cord or\n extrinsic spinal cord compression noted. The prevertebral soft tissue\n thickness is maintained.\n\n IMPRESSION: No evidence of ligamentous disruption seen. No evidence of\n abnormal signal seen within the vertebral bodies to indicate acute trauma.\n Multilevel degenerative changes with foraminal changes as above. No evidence\n of extrinsic spinal cord compression or intrinsic spinal cord signal\n abnormalities.\n (Over)\n\n 1:05 AM\n MR CERVICAL SPINE Clip # \n Reason: ?fx of ligamentus or disc injury\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2178-05-05 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 912143, "text": " 3:42 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: r/o biliary disease\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with transaminitis and recurrent fevers\n REASON FOR THIS EXAMINATION:\n r/o biliary disease\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND\n\n INDICATION: Rule out biliary disease.\n\n ABDOMINAL ULTRASOUND: No prior studies are available for comparison. The\n examination is somewhat limited due to the patient's body habitus. No focal\n liver lesions are noted. There is no intra- or extra-hepatic biliary ductal\n dilatation. The common bile duct is normal measuring 4 mm. The gallbladder\n is without wall thickening or stones. The right kidney measures 12.1 cm. The\n left kidney measures 12.7 cm. There is no hydronephrosis or stones. The\n spleen is normal in size.\n\n IMPRESSION: Examination somewhat limited due to body habitus. No abnormality\n identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-05-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911786, "text": " 2:56 PM\n CHEST (PA & LAT) Clip # \n Reason: prior ?RLL infiltrate, pt still spiking fevers, assess for i\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with DKA, subjective fevers, leukocytosis s/p multiple falls\n\n REASON FOR THIS EXAMINATION:\n prior ?RLL infiltrate, pt still spiking fevers, assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS ON .\n\n HISTORY: Fever, right lower lobe infiltrate.\n\n REFERENCE EXAM: .\n\n FINDINGS: There has been interval improvement in aeration of the previously\n described right lower lobe infiltrate. On today's film, only a small area of\n increased opacity is seen in this region likely representing a small area of\n volume loss.\n\n IMPRESSION: Improved right lower lobe infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-05-03 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 911894, "text": " 5:51 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Evaluate for obstruction or ileus, free air\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with admission for DKA, now with fever, distended abdomen.\n REASON FOR THIS EXAMINATION:\n Evaluate for obstruction or ileus, free air\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND ERECT ABDOMEN ON AT 17:56\n\n INDICATION: Fever and distended abdomen.\n\n FINDINGS:\n\n Air-filled distended loops of both large and small bowel are visualized in a\n pattern most consistent with adynamic ileus. There is no free air or\n pneumatosis. There is no evidence for ascites.\n\n IMPRESSION: Findings most consistent with adynamic ileus. A followup film\n recommended including an image low enough to visualize the inferior pelvis.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-05-07 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 912488, "text": " 3:58 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: S/P FALL, PLEASE EVAL FOR FLUID COLLECTION\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with transaminitis and recurrent fevers. s/p fall with large\n hematoma on R flank. ?fluid collection.\n REASON FOR THIS EXAMINATION:\n please eval for fluid collection.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient with right flank bruising after a fall.\n\n RIGHT LOWER QUADRANT ULTRASOUND, LIMITED\n\n TECHNIQUE: 2D -scale son was performed of the right flank, right\n lower quadrant, and superficial tissues of the right hemi-abdomen.\n\n FINDINGS:\n\n There is no fluid collection within the subcutaneous tissues of the right\n hemi-abdomen, flank, or right back. No fluid is seen within the peritoneal\n cavity along the right side. No hematomas.\n\n IMPRESSION:\n\n No right fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2178-05-04 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 912000, "text": " 5:07 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?interval change. PLEASE INCLUDE PELVIS\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with admission for DKA, now with fever, distended abdomen.\n\n REASON FOR THIS EXAMINATION:\n ?interval change. PLEASE INCLUDE PELVIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old male with DKA, presenting with fever and distended\n abdomen.\n\n COMPARISONS: .\n\n FINDINGS: A nasogastric tube is seen terminating in the proximal stomach.\n There are numerous air-filled distended loops of both large and small bowel,\n which appear unchanged in comparison with the prior study. Air is seen\n projecting over the rectum. There is no evidence of free air or ascites.\n Degenerative changes of the bilateral hip joints are noted.\n\n IMPRESSION: Multiple distended loops of small and large air- filled bowel\n consistent with persistent adynamic ileus.\n\n" }, { "category": "Radiology", "chartdate": "2178-05-06 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 912249, "text": " 9:48 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?resolving ileus. Pt with NGT.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with adynamic ileus.\n REASON FOR THIS EXAMINATION:\n ?resolving ileus. Pt with NGT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known ileus, follow up.\n\n COMPARISON: Abdominal plain film from .\n\n SUPINE AND ERECT ABDOMINAL RADIOGRAPHS: Again seen are distended loops of\n small and large bowel, which are essentially stable in appearance since the\n prior study. There has been interval placement of a nasogastric tube with its\n tip terminating in the stomach. Again seen are mild degenerative changes of\n the thoracolumbar spine.\n\n IMPRESSION: Stable appearance to the distention of the small and large bowel\n loops consistent with ileus.\n\n" }, { "category": "Radiology", "chartdate": "2178-05-07 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 912421, "text": " 10:13 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with adynamic ileus.\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up known ileus.\n\n COMPARISON: Abdominal plain films from one day prior.\n\n MULTIPLE AP VIEWS OF THE ABDOMEN: Again seen are dilated loops of small and\n large bowel, essentially stable since the prior study. Air and stool is seen\n in the rectum. The lung bases appear clear. The nasogastric tube tip is seen\n overlying the stomach. There is no obvious free intraperitoneal air.\n\n IMPRESSION: Stable appearance to the dilated loops of small and large bowel\n as compared to one day prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-05-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 911961, "text": " 12:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?interval change, new ICH\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with R subdural hematoma and delta MS.\n FOR THIS EXAMINATION:\n ?interval change, new ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Right-sided subdural hemorrhage. Change in mental status. Assess\n for interval change or new intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: non-contrast head CT scan reported by Dr.\n as revealing both stable appearance of the brain and subdural\n hematoma compared to the previous study.\n\n Comparison between the two studies is slightly impeded by different scan\n angulations employed for each examination. Within these limitations, there\n may be very slight increase in the width of the left frontal-parietal chronic\n subdural fluid collection. However, there is negligible associated alteration\n in mass effect. The right-sided mixed density cerebral hemispheric subdural\n fluid collection has undergone a reduction in density of the more acute right\n frontal hemorrhagic compartment. There is no change in ventricular size or\n shift of normally midline structures. There is no new underlying brain\n infarction seen.\n\n The surrounding osseous and soft tissue structures show no new abnormality.\n\n CONCLUSION: Slight increase in width of the left frontal-parietal chronic\n subdural fluid collection and some decrease in density of a hyperdense portion\n of the right-sided cerebral convexity subdural hemorrhage. Otherwise,\n relatively stable scan appearance.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-04-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911475, "text": " 9:13 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with DKA, subjective fevers, leukocytosis s/p multiple falls\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: DKA, subjective fevers, leukocytosis, eval for pneumonia.\n\n COMPARISON: None.\n\n FINDINGS: There is a right lower lobe opacity with air bronchonograms that\n likely represents pneumonia. Otherwise the lungs are clear, and the pleura are\n normal. The heart is top normal size, the thoracic aorta is unfolded.\n\n IMPRESSION: Right lower lobe pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2178-04-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 911431, "text": " 7:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval of SDH\n ______________________________________________________________________________\n FINAL ADDENDUM\n CT SCAN OF THE BRAIN.\n\n INDICATION: Multiple falls.\n\n FINDINGS: There is a right-sided acute subdural hematoma, which has collected\n mostly posteriorly, along the occipital and parietal lobes. This measures\n roughly 11.5 mm in maximal width. There is indentation of the left occipital\n lobe and mild anterior displacement of the atrium of the left lateral\n ventricle. The ventricles are midline in position and not enlarged. Basal\n cisternal spaces are well visualized.\n\n There is a subacute left frontal subdural hematoma, which is less than 1 cm in\n maximal width. There is mild displacement of the brain away from the inner\n table. There is only slight narrowing of the sulci. Again, normally midline\n structures are not shifted.\n\n No focal parenchymal attenuation abnormalities are seen. -white matter\n differentiation is preserved throughout. There are no signs of cerebral\n edema.\n\n IMPRESSION: Acute right subdural hematoma and subacute left subdural\n hematoma. This is consistent with the patient's history of multiple falls.\n Findings were discussed with Dr. at 9:52 a.m. on .\n Findings of the cervical spine were discussed at the same time.\n DFDgf\n\n\n 7:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval of SDH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with reported SDH\n REASON FOR THIS EXAMINATION:\n eval of SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JWK WED 8:54 PM\n 1. Right sided SDH.\n 2. Chronic left sided SDH.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old with subdural hematoma.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is a moderate-sized right-sided subdural hematoma with\n associated mass effect. A lower attenuation left- sided extra- axial fluid\n collection likely represents a chronic subdural hematoma. There is no shift\n of the normally midline structures or hydrocephalus. The subcutaneous tissues\n are unremarkable. A linear lucency through the right occipital bone likely\n represents a vascular channel although a fracture cannot be excluded. The\n mastoid air cells and visualized paranasal sinuses are well aerated.\n\n IMPRESSION:\n 1. Moderate-sized right-sided subdural hematoma.\n 2. Left-sided chronic subdural hematoma.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2178-04-29 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 911432, "text": " 7:00 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ?, PT. WITH SDH OSH,FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with reported SDH, AMS\n REASON FOR THIS EXAMINATION:\n c-spine fx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man with subdural hematoma.\n\n No prior studies for comparison.\n\n TECHNIQUE: MDCT axial images of the cervical spine were obtained without IV\n contrast. Sagittal and coronal reformatted images were performed.\n\n FINDINGS: On sagittal images, the base of the skull to T2 vertebrae are\n clearly visualized. Prevertebral soft tissues are not edematous. There is\n grade 1 anterolisthesis of C7 on T1. Degenerative changes of the cervical\n spine, most pronounced at the C5 through C7 levels, where there is disc space\n narrowing and anterior osteophytes. Calcification of the ligamentum nuchae.\n No evidence of acute fracture. CT does not provide intrathecal detail\n comparable to MRI, however there are no gross thecal sac abnormalities. The\n lung apices are unremarkable.\n\n IMPRESSION:\n 1. Grade 1 anterolisthesis of C7 on T1. Flex/extension views are recommended\n for further evaluation, if there are symptoms referable to this region.\n 2. Degenerative changes of the cervical spine.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2178-04-30 00:00:00.000", "description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS", "row_id": 911476, "text": " 9:13 AM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: evluate C-spine\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with DKA, subjective fevers, leukocytosis s/p multiple falls\n with anterior prominence at C7-T1 cannot rule out fracture.\n REASON FOR THIS EXAMINATION:\n evluate C-spine\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Cervical spine flexion and extension views .\n\n HISTORY: 70-year-old man with fevers, leukocytosis and multiple falls.\n Patient with prominence at the C7/T1 junction, evaluate for fracture.\n\n FINDINGS: Flexion and extension views of the cervical spine are limited as\n only C1 through C6 are visualized. There is no abnormal motion with flexion\n or extension in the upper cervical spine. There are extensive degenerative\n changes at C5- C6 and likely C6-C7. Posteriorly, there is a calcific density\n adjacent to the spinous processes of C5-C6 and also that of C7. Prevertebral\n soft tissues are within normal limits. Please refer to the cervical spine CT\n for further details.\n\n IMPRESSION:\n Degenerative changes of the lower cervical spine without signs for ligamentous\n laxity on flexion or extension views of the upper cervical spine. Please\n note that the C7-T1 junction is not imaged..\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2107-06-27 00:00:00.000", "description": "CT EMERGENCY HEAD W/O CONTRAST", "row_id": 765131, "text": " 6:17 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: s/p MCC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with trauma\n REASON FOR THIS EXAMINATION:\n s/p MCC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle accident.\n\n TECHNIQUE: Noncontrast CT exam of the head.\n\n FINDINGS: There is no evidence of intra or extraaxial hemorrhages. There is no\n mass effect or shift of the midline structures. Noted is a punctate focus of\n increased attenuation of the anterior left frontal lobe, near the midline, of\n unknown significance. The ventricles, cisterns and sulci are unremarkable,\n without efacement. The /white matter differentiation is well preserved.\n The visualized soft tissues, paranasal sinuses and osseous structures are\n unremarkable.\n\n IMPRESSION: No evidence of an acute intracranial pathologic process. Punctate\n focus of increased attenuation of the anterior left frontal lobe, as described\n above. A followup CT exam may be helpful, if indicated, to exclude a possible\n early intracranial bleed.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-27 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 765128, "text": " 5:53 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n COMPARISON: None.\n\n TRAUMA SERIES\n\n AP PORTABLE CHEST: An endotracheal tube terminates with its tip above the\n level of the clavicles 8.4 cm above the carina. There is diffuse airspace\n filling of the left lower ling filed compatible with contusion. There may be a\n minimally displaced fracture of the 9th posterior rib on the left. The right\n lung is grossly clear. There is no pneumothorax identified. The mediatinum is\n markedly widened anteriorly and posteriorly. The right and left paratracheal\n stripes are widened and in addition the aortic knob is indistinct.\n\n AP PORTABLE PELVIS: Portions are obscured by the trauma board and\n paraphernalia and a hand is present over the right hip joint. There are no\n displaced fractures evident.\n\n IMPRESSION: 1. Meateked diastinal widening concerning for aortic\n injury.\n\n 2. Pulmonary contusions on the left. Possible fracture of the 9th rib\n posteriorly, though this is overlapped by the trauma board.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765252, "text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: TACHYPNEA, DESATURATION, HYPERTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n\n REASON FOR THIS EXAMINATION:\n TACHYPNEA, DESATURATION, HYPERTENSION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachypnea, hypertension and hypoxemia.\n\n PORTABLE CHEST: Comparison is made to . The endotracheal tube is in a\n high position, almost 10 cm above the carina. The tip of the nasogastric tube\n is in the mid-thoracic esophagus. There is a Swan-Ganz catheter inserted via\n an introducer sheath in the left subclavian vein, with the tip in the right\n main pulmonary artery. The heart size is nomal. There is a stable post-\n operative appearance of the superior mediastinum.\n\n Since the prior exam, there is decreased pulmonary edema. There has also been\n partial clearing of the alveolar opacities in the left lower lobe, consistent\n with aspiration. There are two thoracostomy tubes on the left, with no\n evidence of pneumothorax. A fracture of the left scapula is noted.\n\n IMPRESSION:\n 1) High positioning of endotracheal tube.\n 2) Nasogastric tube tip in mid-esophagus.\n 3) Significantly improved pulmonary edema.\n 4) Partial clearing of left lower lobe aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-29 00:00:00.000", "description": "CHEST CTA WITH CONTRAST", "row_id": 765253, "text": " 5:38 AM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R/O PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n TACHYPNEA, TACHYCARDIA, DESATURATION IN A POST OP PATIENT POD 1 FROM REPAIR OF\n TRAUMATIC RUPTURE OF AORTA.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Recent aortic injury repair with tachypnea, tachycardia and\n desaturations.\n\n TECHNIQUE: Helically acquired CT images are obtained through the pulmonary\n arterial vasculature after and during the administration of 100 cc of Optiray\n nonionic IV contrast. Optiray is utilized given the rapid rate of bolus\n required for the protocol. Multiplanar constructions are reformatted.\n\n Comparison is made to previous films from .\n\n CT CHEST AFTER IV CONTRAST: There is near complete resolution of previously\n seen large mediastinal hematoma. A small amount of fluid and stranding\n remains. There has been repair of previously seen aortic injury. There is NO\n extravasation of contrast at the site of surgical repair. Surgical clips and\n some adjacent air are seen within the mediastinum.\n\n No thrombus or emboli is seen within the pulmonary arterial vasculature. There\n is a moderate sized dependent right sided pleural effusion with minimal right\n basilar atelectasis. There is atelectasis within the basilar segments of the\n left lower lobe. Fluid is seen within the major fissure. Ground glass\n opacities are present Within the aerated regions of the left lower lobe.\n A focal high density fluid collection at the left base is suspicious for\n hematoma. There is no evidence of active extravasation into this region. Two\n chest tubes are seen within the left lung, one within the lower lobe and one\n extending into the apex. There is subcutaneous emphysema around the left\n lateral chest wall. Scattered areas of ground glass and consolidation are also\n seen within the right lung, stable from the prior study. Non displaced left\n sided rib fractures are again seen. The scan does not include the fractured\n regions of the left glenoid and scapula. Multiplanar reconstructions confirm\n the above findings.\n\n\n IMPRESSION:\n\n 1. No pulmonary embolus.\n 2. Post repair of acute aortic injury and near complete resolution of\n mediastinal hematoma.\n 3. Interval formation of moderate to large sized right sided pleural\n effusion.\n 4. Atelectasis in the left base and scattered areas of ground glass opacity\n and consolidation in both lungs which remain concerning for contusion. A focal\n (Over)\n\n 5:38 AM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R/O PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hematoma is present in the left base.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 765159, "text": " 4:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with small puctate L frontal hem s/p aortic injury repair\n REASON FOR THIS EXAMINATION:\n ?bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up possible punctate hemorrhage in motorcycle trauma\n patient.\n\n COMPARISON: .\n\n Three regions of hyperdensity, each measuring less than 5 mm, are seen in the\n anterior frontal lobes, two on the left and one on the right. There are small\n surrounding areas of edema. There is no shift of normally midline structures.\n There is no loss of the /white matter junction. There is no\n hydrocephalus. Again, no skull fracture is identified.\n\n IMPRESSION:\n\n Three punctate intraparenchymal hemorrhages/contusions in the anterior frontal\n lobes medially.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-28 00:00:00.000", "description": "LO LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.", "row_id": 765157, "text": " 2:28 AM\n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R. Clip # \n Reason: STABLIZE L/LEG (TIBIA) FX SITE\n ______________________________________________________________________________\n FINAL REPORT\n Lower extremity fluoroscopy was performed without a radiologist present. 1.4\n minutes of fluoro time were used. No films were submitted.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 765230, "text": " 4:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p MCC - head trauma - is there progression of intracranail\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with small puctate L frontal hem s/p aortic injury repair\n\n REASON FOR THIS EXAMINATION:\n s/p MCC - head trauma - is there progression of intracranail injury?\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Head trauma, is there progression of intracranial injury?\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: Head CT from earlier the same day.\n\n FINDINGS:\n Since the prior study, a new 5mm zone of hypodensity has developed in the\n genu of the right internal capsule- this could be an area of shearing injury.\n\n Again, bilateral frontal punctate intraparenchymal hemorrhages are noted. The\n high attenuation portion is not increased in size; however, there has been a\n slight increase in the surrounding area of low density consistent with\n expected adjacent edema. There is no shift of normally midline structures or\n mass effect. The ventricles have not significantly changed in size. The\n grey/white matter differentiation is preserved. No gross cerebral edema is\n present. No major vascular territorial infarctions are present. There is\n symmetric prominence of the soft tissues overlying the skull which may be due\n to anasarca. No new areas of hemorrhage are noted. No skull fractures are\n seen. A moderate air-fluid level is noted in the left maxillary sinus. This\n likely relates to intubation.\n\n IMPRESSION:\n Probable small shearing injury in genu of the right internal capsule, new\n since prior examination.\n\n Interval evolution of bilateral punctate frontal hemorrhageic contusions, as\n shown by slight increase in surrounding edema. No new hemorrhages or shift of\n normally midline structures.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765281, "text": " 12:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: declining O2 sats\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n\n REASON FOR THIS EXAMINATION:\n declining O2 sats\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Decreasing oxygenation/hypoxia.\n\n COMPARISON: .\n\n CHEST, SINGLE VIEW: The cardiac, mediastinal and hilar contours are stable in\n appearance. Several surgical clips are noted along the left side of the\n superior mediastinum. Again noted, is the ET tube which is 10 cm above the\n carina. The NG tube is again noted extending only to the level of the mid-\n esophagus. The left subclavian pulmonary catheter has been slightly withdrawn\n and now the tip terminates in the pulmonary arterial trunk. A right\n subclavian sheath is again noted. There is no evidence of pneumothorax.\n Allowing for differences in motion and technique, there has been no interval\n change in the pulmonary edema or left lower lobe opacity. Again noted, is the\n left scapula fracture. A left-sided chest tube is noted with tip abutting the\n mediastinal surface, unchanged from prior study. Numerous surgical staples\n are noted overlying the left upper lobe.\n\n IMPRESSION:\n 1) Unchanged pulmonary edema and left lower lobe aspiration.\n\n 2) Very high positioning of ET tube. This should be advanced by at least\n 3 cm.\n 3) NG tube tip again noted in mid-esophagus. This should be advanced by at\n least 15 cm.\n\n These findings were communicated with the clinical staff shortly after the\n study was performed.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-29 00:00:00.000", "description": "CHEST CTA WITH CONTRAST", "row_id": 765282, "text": " 1:02 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: acute desaturation, chest CTA to eval for PE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n\n REASON FOR THIS EXAMINATION:\n acute desaturation, chest CTA to eval for PE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a 23 year old man who is status post repair for traumatic\n aortic tear who has acute onset of shortness of breath.\n\n TECHNIQUE: Multiple axial images were obtained from the chest following the\n administration of IV contrast using the CT angiography chest protocol.\n\n COMPARISON: and .\n\n CONTRAST: 150 cc Optiray was administered secondary to fast rate of\n injection.\n\n CT OF THE CHEST AFTER IV CONTRAST: Again noted is the mediastinal hematoma\n which compared to the last study has not changed significantly in size. There\n is no extravasation of contrast seen. Surgical clips and some air are seen\n adjacent to the prior site of injury.\n\n There are no filling defects seen in the pulmonary arteries to the level of\n the lobar branches. The heart and pericardium are unremarkable. On the right\n side, there is a pleural effusion seen associated with compressive\n atelectasis. This has not changed in size compared to the prior study. On\n the left side, there are two chest tubes seen which enter the mid portion of\n the chest. One chest tube goes superiorly towards the apex, the other goes\n inferiorly to the base of the lung. There is subcutaneous emphysema seen at\n the entry site for the chest tubes. In the apex of the left lung there is a\n very small pneumothorax seen. In the base of the left lung there is an\n opacity seen that has a few air bronchograms. This is consistent with a\n consolidation or possible aspiration, or possibly atelectasis. Throughout\n both lungs there are scattered areas of ground glass opacity with\n consolidations that are consistent with contusions. In addition, in the apex\n of both lungs, there are thickened interlobular septa that are consistent with\n pulmonary edema. The focal area of opacity seen in the left lung base is\n again noted and is unchanged compared to the prior study. There is a\n nasogastric tube seen. The visualized portion of the upper abdomen is within\n normal limits.\n\n BONE WINDOWS: Again noted is a left non-displaced anterior rib fracture. The\n previously-reported glenoid and scapular fractures are not visualized.\n\n Multiplanar reconstructions confirm the above findings.\n\n (Over)\n\n 1:02 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: acute desaturation, chest CTA to eval for PE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1) No pulmonary embolus.\n\n 2) Status post repair of aortic injury with no significant change within the\n site of the mediastinal hematoma.\n\n 3) There is a right-sided pleural effusion which has not changed compared to\n the last study.\n\n 4) There is a left lower lobe consolidation most consistent with aspiration\n pneumonia.\n\n 5) There is apical septal thickening consistent with pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765293, "text": " 6:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: to see the tip of chest tube on rt. side.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n to see the tip of chest tube on rt. side.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 23-year-old trauma patient evaluate chest tube.\n\n AP portable semi-upright chest radiograph dated is compared to\n the prior study performed five hours earlier.\n\n FINDINGS: The endotracheal tube is again noted to be 9 cm above the level of\n the carina. The nasogastric tube is again noted to be in the distal esophagus.\n The Swan Ganz catheter is satisfactorily placed within the pulmonary artery.\n A right subclavian introducer sheath is seen. Two left-sided chest tubes are\n seen. There has been interval placement of the right-sided chest tube\n terminating within the right apex. No pneumothorax is seen.\n\n There is persistent widening of the mediastinum, consistent with the patient's\n history of aortic injury. The cardiac contours are within normal limits. There\n has been interval improvement in the appearance of the pulmonary edema.\n However, there is a persistent left lower lobe opacification. Surgical clips\n are seen along the left hemithorax. There is a left scapular fracture.\n\n IMPRESSION:\n 1. The endotracheal tube tip terminates superior to the thoracic inlet\n approximately 10 mm from the level of the carina. This needs to be advanced by\n approximately 5 mm.\n 2. The nasogastric tube terminates within the distal esophagus and needs to be\n advanced at least 15 mm.\n 3. Interval improvement in the appearance of the pulmonary edema.\n 4. Persistent left lower lobe opacification.\n 5. Interval placement of right chest tube with tip terminating in the right\n apex.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-27 00:00:00.000", "description": "B FOREARM (AP & LAT) BILAT", "row_id": 765142, "text": " 9:48 PM\n FOREARM (AP & LAT) BILAT; HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n SHOULDER 1 VIEW LEFT IN O.R. PORT; TIB/FIB (AP & LAT) LEFT IN O.R. PORT\n HIP 1 VIEW LEFT IN O.R. PORT\n Reason: trauma, trauma, trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with trauma\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma\n\n Mottled images obtained from the O.R. Anterior view of the right shoulder\n reveals no fracture or injury to the proximal left humerus. Portable study of\n the forearm reveals a joint space fracture through the distal right radius\n extending into the joint space. On the lateral view bone fragments are also\n noted posterior to the bones of the wrist but the images cannot be further\n evaluated given the presence of a cast.\n\n IMPRESSION: Transverse intra-articular fracture through distal right radius\n additional fractures in carpal bones cannot be further evaluated given the\n presence of a cast.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765183, "text": " 10:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: to locate tip of lt. subclavian PA catheter. to r/o pthx.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n to locate tip of lt. subclavian PA catheter. to r/o pthx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for pneumothorax, s/p subclavian PA catheter.\n\n FINDINGS: AP supine chest radiograph of is compared to a prior AP\n chest radiograph of . There is a left subclavian line with its tip in\n the right MPA. There are two chest tubes present in the left upper lobe.\n There is no pneumothorax. There is continued mediastinal widening with\n bilateral apical capping suggestive of a mediastinal hematoma. There is\n bilateral pulmonary edema with aspiration present. The ETT is at the level of\n the thoracic inlet. Also noted are surgical staples overlying the left\n hemithorax.\n\n IMPRESSION:\n 1) Pulmonary edema vs. aspiration.\n 2) Mediastinal widening which on CT of the chest showed an aortic\n transsection.\n 3) Satisfactory positioning of the Swan-Ganz catheter in the RMPA.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-27 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 765132, "text": " 6:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: ? INTERNAL INJURY; S/P MCA\n Field of view: 43 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with trauma\n REASON FOR THIS EXAMINATION:\n s/p MCC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle accident. Mediastinal widening seen on\n chest radiograph.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained through\n the chest, abdomen and pelvis after the administration of IV contrast,\n according to the trauma protocol. Delayed images were also obtained through\n the abdomen and pelvis to better evaluate the urinary bladder and ureters.\n\n CT OF THE CHEST WITH IV CONTRAST: A traumatic tear is seen within the\n proximal descending aorta, at the level of the pulmonary ligament, with an\n associated pseudo-aneurys. There is a significant amount of soft tissue\n density within the mediastinum, likely representing hematoma. There is no\n gross extravasation of the intravenous contrast into the adjacent mediastinal\n structures. There does not appear to be involvement of the major branches of\n the aortic arch. Lung windows demonstrate diffuse hazy opacities throughout\n both lungs, likely representing multiple pulmonary contusions. There is near-\n complete opacification with air space filling of the left lower lobe with\n associated non- visualization and irregularity of the left lower lobe\n bronchus. There is concern of a vascular injury in the vicinity of this\n bronchus. There is a tiny anterior left pneumothorax.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, adrenal glands,\n kidneys, pancreas and unopacified loops of large/small bowel are unremarkable.\n There is a trace amount of free fluid within the abdomen. Noted are\n diminutive vessels, likely related to the patient's shocked physical\n condition. There is no evidence of free air within the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: The ureters and urinary bladder are normal\n in appearance. There is no evidence of contrast extravasation to suggest\n ureteral or urinary bladder injury. The rectum, unopacified loops of bowel\n and prostate gland are unremarkable. There is no evidence of free air within\n the pelvis.\n\n Bone windows show a non-displaced fracture of the left anterior glenoid. There\n is also a non-displaced fracture of the left scapula. No additional acute\n fractures are dislocations are identified.\n\n IMPRESSION:\n 1) Traumatic tear of the proximal descending aorta, at the level of the\n pulmonary ligament, with associated mediastinal hematoma.\n (Over)\n\n 6:17 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: ? INTERNAL INJURY; S/P MCA\n Field of view: 43 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2) Diffuse pulmonary contusions with extensive hemorrhage involving the left\n lower lobe, as described above. Non-visualization and irregularity of the\n left lower lobe bronchus suggest the possibility of an associated bronchial\n injury or tear of an adjacent bronchial vein causing hemorrhage into the left\n lower lobe bronchus. The surgical team was informed about these findings in\n the OR.\n\n 3) Fractures of the left glenoid and scapula, as described above.\n\n 4) Small left anterior pneumothorax.\n\n The above findings were discussed in detail with the Surgical and Trauma house\n staff at the time of the examination.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-27 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 765133, "text": " 6:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: S/P MCC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVA, unresponsive.\n\n TECHNIQUE: Contiguous axial images were obtained through the cervical spine\n without IV contrast. Multiplanar reformatted images were also obtained.\n\n FINDINGS: There is no evidence of acute fractures, malalignment, areas of bone\n destruction or other osseous abnormalities. The intervertebral disk spaces\n are well preserved. The visualized soft tissues are grossly normal.\n\n Multiplanar reformatted images confirm the above findings.\n\n IMPRESSION: No evidence of cervical spine fractures or malalignment.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-28 00:00:00.000", "description": "B WRIST(3 + VIEWS) BILAT", "row_id": 765223, "text": " 4:02 PM\n WRIST(3 + VIEWS) BILAT; HAND (AP, LAT & OBLIQUE) BILAT Clip # \n Reason: is there a fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with s/p motor cycle accident\n REASON FOR THIS EXAMINATION:\n is there a fracture?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle accident, assess for fracture.\n\n LEFT HAND/WRIST, THREE VIEWS: These images show no fracture or dislocation.\n\n RIGHT HAND/WRIST, THREE VIEWS: Cast material obscures underlying bony detail.\n There is a displaced intra-articular fracture involving the radial styloid,\n with volar displacement of the distal fragment. A bony fragment is also seen\n dorsal to the carpal bones on the lateral view which is consistent with a\n triquetral fracture.\n\n IMPRESSION:\n 1. Right wrist - triquetral fracture and displaced intra-articular radial\n styloid fracture.\n 2. Left wrist - no fracture identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-28 00:00:00.000", "description": "T-SPINE", "row_id": 765222, "text": " 4:02 PM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: is there a fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n is there a fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. Assess for fracture.\n\n T SPINE, TWO VIEWS: The patient has an ET tube with tip at thoracic inlet. An\n NG tube is seen with tip well above the GE junction, and should be advanced\n further. There is a left-sided Swan-Ganz catheter with tip in the right\n distal pulmonary artery. A portion of a left chest tube is seen. A portion\n of a right subclavian central venous catheter is seen. There are surgical\n clips overlying the left upper hemithorax. The visualized vertebral body\n heights and disc spaces are preserved. No fracture is seen.\n\n L SPINE, TWO VIEWS: No fracture or dislocation is seen.\n\n IMPRESSION: No fracture identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765550, "text": " 5:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desaturation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n desaturation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW:\n\n HISTORY: Desaturation, status post lung contusion.\n\n FINDINGS: There is a Swan-Ganz catheter with tip in the left main pulmonary\n artery. Two left chest tubes and right chest tube are unchanged. The NG tube\n tip is in the stomach. There is continued hazy opacity in the left lower lobe\n consistent with infiltrate. This is not significantly changed compared to the\n film from earlier the same day. Left sided skin staples are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765321, "text": " 10:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: declining O2 sats, STAT portable chest\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n declining O2 sats, STAT portable chest\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 23 y/o trauma patient with hypoxia.\n\n PORTABLE AP CHEST is compared to prior study of 5 hours earlier.\n\n The ET tube is again noted to be 10 cm above the level of the carina. The NG\n tube is seen terminating within the distal esophagus. The right subclavian\n introducer sheath is in stable position. The pulmonary artery catheter\n terminates within the main pulmonary artery. Again noted, are two left-sided\n chest tubes and one right apical chest tube. There is persistent widening of\n the mediastinum. The cardiac contour is stable. There is persistent\n bibasilar opacities more pronounced within the left lower lobe. Their\n appearance is unchanged compared to prior study. A fracture is seen within\n the 5th posterior rib on the left side.\n\n IMPRESSION:\n 1) ET tube suboptimally located 10 cm above level of carina.\n\n 2) NG tube suboptimally located within distal esophagus.\n\n 3) Persistent bibasilar opacification, most pronounced within the left lower\n lobe. This appearance is unchanged, compared to prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-01 00:00:00.000", "description": "L KNEE (2 VIEWS) LEFT", "row_id": 765497, "text": " 8:44 PM\n KNEE (2 VIEWS) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: LT TIBIAL PLATEAU FX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left tibial plateau fracture.\n\n FINDINGS: Ten images from the O.R. demonstrate placement of plate with five\n screws with an adjacent separate screw spanning the region of the proximal\n femur. The alignment is much improved compared to the CT scan dated .\n\n" }, { "category": "Radiology", "chartdate": "2107-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765582, "text": " 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Trauma with infiltrate.\n\n Reference exam: at 1:42.\n\n CHEST, AP PORTABLE: There has been interval increase in left lower lobe\n volume loss with mediastinal shift to the left. There is hazy opacity to the\n left lung, consistent with effusion. Two left chest tubes are unchanged. The\n right chest tube is unchanged. The left subclavian SG catheter with tip in\n the pulmonary outflow tract.\n\n IMPRESSION: Probable left lower lobe collapse.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-04 00:00:00.000", "description": "CHEST FLUORO", "row_id": 765666, "text": " 4:16 PM\n CHEST FLUORO Clip # \n Reason: ? L phrenic nerve injury, please do chest fluoro to assess d\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n ? L phrenic nerve injury, please do chest fluoro to assess diaphragm movement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left thoracotomy for trauma. Now difficult to\n extubate. Rule out left phrenic nerve injury.\n\n COMPARISONS: None.\n\n CHEST FLUOROSCOPY: Study is limited by intubation status and supine\n positioning. However, patient was able to breath voluntarily, making\n assessment of diaphragm movement possible. Right diaphragm and hilum have\n normal motion with respiration. Left diaphragm and hilum have slightly\n paradoxical or no motion with respiration.\n\n IMPRESSION: Findings are highly suggestive of left diaphragm paralysis.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765570, "text": " 1:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia reference exam .\n\n FINDINGS: In comparison to the film from the prior day there has been no\n significant change in the chest tubes, Swan-Ganz catheter, NG tube. There is\n a small right apical pneumothorax which is more apparent on the current than\n prior film. This is likely due to positioning. There is a possible small left\n apical pneumothorax as well. There continues to be dense consolidation of the\n left lower lobe consistent with infiltrate, volume loss, effusion.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-06 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 765853, "text": " 1:43 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Hyperbillirubinemia, liver lac, reassess, please\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n Hyperbillirubinemia, liver lac, reassess, please\n ______________________________________________________________________________\n FINAL REPORT\n LIVER ULTRASOUND, PORTABLE STUDY:\n\n INDICATION: Liver laceration, hyperbilirubinemia.\n\n Portable ultrasound of the liver reveals no ductal dilatation or perihepatic\n fluid collections. No intrahepatic abnormalities are noted. The gallbladder\n is filled with sludge. No gallbladder wall thickening or edema in the wall is\n identified.\n\n IMPRESSION: Sludge in gallbladder lumen. No intra or extrahepatic bile duct\n dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-06 00:00:00.000", "description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS", "row_id": 765879, "text": " 5:24 PM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: r/o c spine instability\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p MCC with tenderness c spine on exam\n REASON FOR THIS EXAMINATION:\n r/o c spine instability\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE 2 VIEWS LATERAL FLEXION & EXTENSION:\n\n HISTORY: MVA with neck tenderness.\n\n C1 to C7 are included. No fracture and no evidence of instability on lateral\n flexion and extension. The prevertebral soft tissues are unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2107-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765350, "text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EVALUATE LUNG CONTUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n EVALUATE LUNG CONTUSION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up lung contusion.\n\n PORTABLE CHEST: Comparison is made to . The endotracheal tube is\n approximately 8.5 cm above the carina. There is a single chest tube on the\n right and two chest tubes on the left. The tip of the Swan-Ganz catheter is\n in the right main pulmonary artery. The superior mediastinum is decreased in\n width, consistent with improving post-operative appearance. The pulmonary\n edema present on the prior study has nearly completely resolved. The alveolar\n opacities in the left lower lobe, consistent with aspiration, are unchanged.\n A left scapular fracture is again noted.\n\n IMPRESSION: 1) High positioning of endotracheal tube.\n 2) Near resolution of pulmonary edema.\n 3) Continued left lower lobe alveolar opacities, likely due to aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767438, "text": " 7:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt w/ SOB, check for effustion, etc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p trauma\n\n REASON FOR THIS EXAMINATION:\n pt w/ SOB, check for effustion, etc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP UPRIGHT CHEST RADIOGRAPH .\n\n CLINICAL INDICATION: Trauma, shortness of breath.\n\n COMPARISON: .\n\n The right chest tube has been removed. The heart size, mediastinal and hilar\n contours are normal. The pulmonary vascularity appears normal. There is\n slight opacity at the left base with a small air fluid level (? related to\n recent thoracentesis). There are metallic surgical clips overlying the left\n superior mediastinum. Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Possible small fluid/air collection in pleural cavity at the left\n lung base. Follow- up is recommended to ensure resolution.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-12 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 766313, "text": " 2:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CHEST CTA WITH CONTRAST; CT RECONSTRUCTION\n CT 150CC NONIONIC CONTRAST\n Reason: ?obstruction, occult abdominal injury. Please put contrast d\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man 12d s/p motorcycle crash with aortic tear, multiple long bone\n fx, s/p post pyloric feeding tube placement now c/o sudden nausea and\n vomiting 200 bilious emessis and o2 desat 95 to 88.\n REASON FOR THIS EXAMINATION:\n ?obstruction, occult abdominal injury. Please put contrast down tube and give\n orally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 y/o man status post motor vehicle crash with aortic\n pseudoaneurysm and now with sudden nausea and bilious vomiting.\n\n TECHNIQUE: Helically acquired contiguous axial images of the abdomen and\n pelvis with oral and intravenous contrast.\n\n CONTRAST: Oral contrast and 150 cc Optiray IV due to fast bolus.\n\n CT ABDOMEN WITH IV CONTRAST: There is peritoneal fluid. The liver, spleen,\n pancreas, adrenal glands and kidneys are unremarkable. Opacified loops of\n small and large bowel are normal in contour and caliber. There is no evidence\n of duodenal hematoma. The gallbladder is unremarkable.\n\n CT PELVIS WITH IV CONTRAST: There is minimal air within the bladder likely\n from prior Foley catheter insertion. There is free fluid.\n\n The osseous structures are intact.\n\n CONCLUSION:\n 1) There is free intraperitoneal fluid but there is no evidence of visceral\n abdominal injury. There is no pneumoperitoneum. There is no evidence of\n pancreatic transection.\n\n CT CHEST WITH CTA PROTOCOL\n\n INDICATION: Patient is status post aortic transection with pseudoaneurysm and\n graft repair. Shortness of breath.\n\n TECHNIQUE: Helically acquired contiguous axial images of the chest using a\n CTA protocol.\n\n CONTRAST: 100 cc Optiray IV due to fast bolus.\n\n COMPARISON: Chest CTA .\n\n CT CHEST WITH IV CONTRAST: There is a new large pericardial effusion. There\n is flattening of the right ventricle, a finding which may be seen with\n (Over)\n\n 2:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CHEST CTA WITH CONTRAST; CT RECONSTRUCTION\n CT 150CC NONIONIC CONTRAST\n Reason: ?obstruction, occult abdominal injury. Please put contrast d\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n constrictive physiology. There is no evidence of pulmonary embolism. There\n is left lower lobe atelectasis with regions of consolidation and likely\n pulmonary contusions. There is a small left pleural effusion. There is a\n small left pneumothorax, approximately 5-8%. There is no evidence of tension.\n Subsegmental atelectasis is present at the right base.\n\n CONCLUSION:\n\n 1) There is no pulmonary embolism.\n 2) Large, likely constrictive, pericardial effusion.\n 3) Small left pleural effusion with atelectasis and likely pulmonary\n contusions.\n 4) Small left pneumothorax.\n 5) Results were discussed with Dr. shortly after the time of\n the examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-13 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 766402, "text": " 3:12 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please evaluate for swallowing\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for swallowing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 year old man with multiple fractures post trauma. Evaluate\n swallowing.\n\n VIDEO OROPHARYNGEAL SWALLOW: Premature spillage and vallecular residue were\n noted with multiple consistencies of barium. The 13 mm barium tablet became\n lodged in the vallecula causing reflex coughing. This was cleared by\n swallowing a spoonful of pudding afterwards. There was no aspiration\n witnessed.\n\n IMPRESSION: Please see the report of speech and swallowing for a detailed\n description of the findings and for recommendations.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766649, "text": " 11:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o collapsed lung or pneumo as pt with back pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p trauma\n\n REASON FOR THIS EXAMINATION:\n r/o collapsed lung or pneumo as pt with back pain\n ______________________________________________________________________________\n FINAL REPORT\n IMPRESSION: Continued left lower lobe atelectasis. No pneumothorax.\n Continued small left pleural effusion.\n\n COMMENT: Portable AP radiograph of the chest is reviewed and compared to\n previous study of .\n\n The patient is status post repair of the transection of the aorta. Two\n mediastinal drains remain in place. There is continued small ___ left pleural\n effusion with left lower lobe atelectasis. The lungs are clear otherwise.\n The heart is normal in size. The left subcavian catheter is in the superior\n vena cava. No pneumothorax is identified.\n\n The previously identified small air adjacent to the left hemidiaphragm is not\n seen.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-01 00:00:00.000", "description": "L CT LOWER LIMB W/O CONTRAST LEFT", "row_id": 765443, "text": " 9:24 AM\n CT LOWER LIMB W/O CONTRAST LEFT; CT RECONSTRUCTION Clip # \n Reason: evaluate for L knee fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate for L knee fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 y/o man with left knee fracture.\n\n TECHNIQUE: Contiguous axial images were obtained of the left knee joint with\n additional coronal and sagittal reconstructions.\n\n CT LEFT KNEE W/O CONTRAST: There is a markedly comminuted tibial plateau\n fracture predominantly involving the lateral compartment. There is minimal\n extension of this fracture into the medial compartment which closely\n approximates the articular surface posteriorly. The largest gap in the\n articular surface anteriorly is approximately 2 cm. The largest gap within\n the articular surface posteriorly is approximately 8 mm. These gaps produce a\n large trough which about 2 cm deep. The most anterior lateral aspect produces\n an 8 mm articular surface depression. There is a small fracture of the\n proximal fibula. External fixator is seen with a screw through the proximal\n tibial metaphysis.\n\n IMPRESSION: Markedly comminuted tibial plateau fracture & small fibular\n fracture.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-01 00:00:00.000", "description": "CT UPPER LIMB W/O CONTRAST", "row_id": 765448, "text": " 10:21 AM\n CT UPPER LIMB W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r WRIST TO EVALUATE FOR FRACTURES.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n r WRIST TO EVALUATE FOR FRACTURES.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. Evaluate for fractures.\n\n TECHNIQUE: Contiguous axial images of the right wrist were obtained in the\n parasagittal plane. Axial and coronal reconstructions were performed.\n\n CT SCAN RIGHT WRIST W/O CONTRAST: The study is suboptimal due to patient's\n intubated state and splint about the right wrist (images had to be obtained in\n the sagittal plane). There is a comminuted intra articular fracture of the\n distal radius predominantly involving the volar, lateral surface. Noted is a\n radial styloid fracture. The triquetrium is fractured with fracture fragment\n seen dorsally. There is a probable fracture of the capitate near the\n carpometacarpal joint. There is a transverse fracture through the shaft and\n involving the base of the second metacarpal. There is a probable comminuted\n fracture at the base of the fourth metacarpal.\n\n IMPRESSION: Comminuted intra articular fracture of distal radius. Fracture of\n the triquetrium and second metacarpal. Probable fractures of the capitate and\n base of fourth metacarpal.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766280, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: O2 destaturation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n O2 destaturation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: O2 desaturation.\n\n SINGLE AP VIEW OF THE CHEST is compared to a previous study dated .\n\n The feeding tube is appropriately positioned. There are two left-sided chest\n tubes,unchanged in position. There is no evidence of pneumothorax. The\n right lung is clear. There is dense opacification involving the retrocardiac\n area which is significantly increased in comparison with previous study. There\n is blunting of the AP angle as well. There are rib fractures and left scapula\n fractures which are unchanged.\n\n IMPRESSION: New retrocardiac opacity which is suspicious for an infection and\n less likely atelectasis. There is also left-sided pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-08 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 766061, "text": " 2:59 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o DVT - s/p MCC, bedrest with multiple long bone fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n r/o DVT - s/p MCC, bedrest with multiple long bone fx\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY DEEP VENOUS STUDY.\n\n INDICATION: 23 year old man, bed rest after multiple long bone fractures.\n\n Ultrasound Doppler of the long saphenous vein, common femoral vein,\n superficial femoral vein and popliteal vein was performed bilaterally.\n\n No thrombus was observed on those vessels. There is normal compressibility of\n these veins. There is normal color flow, waveform and augmentation.\n\n IMPRESSION: No DVT was observed in both thighs.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765527, "text": " 9:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICAITON: 23 year old male with shortness of breath, rule out pneumonia.\n\n FINDINGS: Comparison is made to study dated . There has been interval\n removal of an endotracheal tube. Swan-Ganz catheter has been advanced, with\n tip now in the right main pulmonary artery. An NG tube is again seen, with\n its tip now above the diaphragm; this should be advanced.\n\n The cardiomediastinal silhouette is within normal limits. Surgical staples\n are again noted within the soft tissues overlying the left upper thorax.\n There is interval increase in ill-defined confluent opacities in the left\n lower lobe, suspicious for pneumonia. There is no pleural effusion or\n pneumothorax. Two left-sided chest tubes and one right-sided chest tube are\n again noted, unchanged in position.\n\n IMPRESSION: Developing pneumonia in the left lower lobe. Interval removal of\n ET tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766498, "text": " 8:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p extubation. chest pressure. sob. . breath sounds on l\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p trauma\n REASON FOR THIS EXAMINATION:\n s/p extubation. chest pressure. sob. . breath sounds on lt. r/o pneumotx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath and decreased breath sounds on the left.\n\n Single view of the chest is compared to a previous study performed earlier\n that day.\n\n The ETT has been removed. There are mediastinal drainage catheters and skin\n staples overlying the left thorax. There is almost complete opacification of\n the left hemithorax. The trachea is midline, but the heart is shifted to the\n left suggesting some volume loss. The right lung is clear.\n\n There is a linear lucency beneath the left hemidiaphragm probably related to\n recent surgery. The left subclavian line is within the brachiocephalic vein.\n\n IMPRESSION:\n\n Almost complete opacification of the left hemithorax with volume loss,\n probably representing atelectasis.\n\n The linear lucency beneath the diaphragm is probably post surgical free air.\n\n The findings were discussed with the SICU resident at 9:45 a.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766451, "text": " 10:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX OR EFFUSION. S/P PERICARDIAL WINDOW\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man\n\n REASON FOR THIS EXAMINATION:\n PTX OR EFFUSION. S/P PERICARDIAL WINDOW\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Creation of a pericardial window.\n\n Single view of the chest is compared to a previous study dated .\n\n The ETT and left subclavian line are appropriately positioned. The cardiac\n contours are stable. There is removal of a catheter overlying the left heart\n border. There are drainage catheters overlying the right heart border. There\n are new illdefined opacity within the right middle, left lower and left upper\n lobe. There is no pneumothorax. There are skin staples overlying the left\n chest.\n\n IMPRESSION:\n\n Multifocal hazy opacities which probably represent effusion and atelectasis at\n the left base. The left upper and the right middle lobe opacity may represent\n aspiration although infection would have a similar appearance. There is also a\n more dense pleural based consolidation in the left upper lobe which may\n represent a loculated pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765596, "text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: status post line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n status post line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, AT 13:07:\n\n REFERENCE EXAM: at 9:48.\n\n FINDINGS: There is a new ETT with tip 6 cm above the carina, slightly high.\n There is improved aeration in the left lung with decrease in the mediastinal\n shift. However, there continues to be left lower lobe dense\n consolidation/volume loss with patchy infiltrate on the left and a layering\n effusion. The two left chest tubes are unchanged. The right chest tube and\n right subclavian line are unchanged. The Swan-Ganz catheter has been removed.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-11 00:00:00.000", "description": "N-G TUBE PLACEMENT (W/ FLUORO)", "row_id": 766190, "text": " 9:02 AM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: PLEASE PLACE POSTPYLORIC DUBHOFF FOR FEEDING\n Contrast: CONRAY Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man WITH POOR PO INTAKE\n REASON FOR THIS EXAMINATION:\n PLEASE PLACE POSTPYLORIC DUBHOFF FOR FEEDING\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Poor PO intake.\n\n POST PYLORIC FEEDING TUBE PLACEMENT BY RADIOLOGIST UNDER FLUOROSCOPIC\n GUIDANCE: An 8 french post pyloric feeding tube was advanced through the nasal\n cavity, esophagus, stomach and beyond the pylorus without difficulty. The tip\n resides in the third portion of the duodenum.\n\n IMPRESSION: Successful feeding tube placement.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766145, "text": " 8:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube has air oleak\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with .\n\n REASON FOR THIS EXAMINATION:\n chest tube has air oleak\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE AP CHEST.\n\n HISTORY: Chest tube with air leak.\n\n The heart is at the upper limits of normal in size. There is considerable\n density at the left base, raising the question of consolidation in the\n retrocardiac segments of the left lower lobe. There are two chest tubes in\n the left hemithorax. There is no evident pneumothorax. Numerous skin staples\n are present in the upper lateral aspect of the left hemithorax and there are\n hemostasis clips around the left hilum. The patient has been extubated and an\n NGT has been removed. The right lung is clear.\n\n IMPRESSION:\n 1) No evidence of pneumothorax.\n\n 2) Possible left lower lobe consolidation,somewhat improved since .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766300, "text": " 11:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal and central line placement.\n\n COMPARISON: .\n\n AP CHEST: There is a small left sided pneumothorax. Two chest tubes have\n been removed. A left subclavian central line has been positioned with its tip\n at the confluence of the brachiocephalic and SVC. A feeding tube is\n unchanged. The cardiac silhouette has progressively enlarged since admission\n studies, and the right heart contour overlies the hilum. There is lobulated\n opacity adjacent to the left heart contour and there is continued dense\n retrocardiac opacity on the left. There is no effusion identified. The lungs\n are otherwise clear. Skin staples remain present over the left hemithorax\n and the previously demonstrated rib fractures are not well seen.\n\n IMPRESSION:\n 1) Small left pneumothorax post chest tube removal and central line placement.\n 2) Subclavian line tip in proximal SVC.\n 3) Enlarging cardiac silhouette compared to earlier radiographs raising\n possibility of pericardial effusion. Correlative echocardiogram may be\n helpful.\n 4) Persistent retrocardiac opacity, representing collapse and/or consolidation\n left lower lobe.\n 5) Lobulated appearance adjacent to the heart may represent loculated\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766346, "text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX OR EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man\n\n REASON FOR THIS EXAMINATION:\n PTX OR EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n PORTABLE AP CHEST:\n\n Comparison: .\n\n A left subclavian line is visualized with tip within the superior vena cava.\n There is noted progressive effusion in the left lung. This appears to be\n loculated at the apex. No pneumothorax is visualized. Increased hilar and\n left ___paracardiac area opacity is also noted. This is likely associated\n with atelectasis and pleural effusion. There are no other new focal opacities\n or consolidations.\n\n IMPRESSION:\n\n 1. Progression of left pleural effusion, loculated at the apex.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766474, "text": " 2:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for atelectasis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man\n REASON FOR THIS EXAMINATION:\n evaluate for atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for atelectasis. Study is compared to the prior\n examination of the same day at 10:36 hours.\n\n FINDINGS: An endotracheal tube is seen approximately 6 cm above the carina. A\n left subclavian central venous line is seen with its tip in the junction of\n the brachiocephalic vein and SVC. Two chest tubes are seen to enter the lower\n right hemithorax.\n\n The heart and mediastinal and hilar contours are unchanged from prior\n examination. There is no evidence of pulmonary vascular congestion. There is\n a left pleural effusion noted to be loculated in the left upper lobe. There is\n left lower lobe atelectasis and consolidation, largely unchanged from prior\n examination. There is also hazy opacity seen in the left middle lobe.\n\n The soft tissue and osseous structures remain stable.\n\n IMPRESSION: No interval change from prior examination. Persistent left\n loculated pleural effusion and left middle and lower lobe atelectasis and\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766520, "text": " 9:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CONGESTION AND/OR EFFUSION ON LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p trauma\n\n REASON FOR THIS EXAMINATION:\n CONGESTION AND/OR EFFUSION ON LEFT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestion or trauma in the left, follow up.\n\n Single view of the chest is compared to a previous study dated at 9 p.m.\n\n The left subclavian line and mediastinal drains are unchanged. There is\n improved aeration of the left lung. There is residual opacity at the left base\n suggesting atelectasis and effusion. There is also left apical capping\n suggesting a loculated effusion. The overlying skin staples in the left\n thorax. Again seen is a linear lucency beneath the left hemidiaphragm. There\n is also linear opacities in the right middle lobe.\n\n IMPRESSION:\n\n Improved aeration of the left lung with residual opacity in the right mid and\n left lower lobe consistent with atelectasis and left sided effusion.\n\n Again seen is a linear lucency beneath the left hemidiaphragm.\n\n The findings were discussed with the SICU resident at the time of the\n examination.\n\n" }, { "category": "Nursing/other", "chartdate": "2107-07-15 00:00:00.000", "description": "Report", "row_id": 1598777, "text": "NURSING PROGRESS NOTE\nS/ PT C/O OF PAIN AT SURGICAL SITE USING PCA EFFECTIVELY BUT GETTING LITTLE RELIEF. WEANED PT ON WITH GOOD GAS, PT LOOKED MORE COMFORTABLE AND WAS EXTUBATED. PT TO 88. NC ADDED TO FACE MASK OF 100 % AND SATS IMPROVED TO 95. ONE U PC WAS TRANSFUSED FOR HCT OF 26 AND SATS GRADUAL ROSE TO 98-100%. PT TO USE PCA AND STILL C/O PAIN, THEN BEGAN C/O PRESSURE IN HES CHEST AND DIFFICULTY TAKING DEEP BREATHS. PT BECAME MORE TACHYCARDIC AND B/P INCREASED. DESPITE REPOSITIONING, PRESSURE REMAINED . CXR DONE, WHITE OUT IN L LUNG, MORPHINE WAS CHANGED TO HYDROMORPHONE WITH SOME IMPROVEMENT IN PAIN RELIEF AND PT WAS GIVEN CPT BOTH RT AND LT, AGAIN ON LEFT SIDE 30MIN LATER, DURING THIS CPT PT WAS ABLE TO MOBILIZE AN ENORMOUS PLUG OF THICK YELLOW SPUTUM. PT THEN STATED THAT HE COULD BREATH EASIER AND THE PRESSURE HAD LESSONED AND OVERALL FELT BETTER. STILLC/O PAIN WITH COUGHING. BREATH SOUNDS IMPROVED BILATERALLY.\n PT TACHYCARDIC WITH STABLE B/P\nGU- GOOD U/O, IVF OF 125CC DISCONTINUED NOW AT KVO.\n PT ON TPN AT 86 CCHR, GLUCOSE 136. PT TAKING IN JELLO AND PUDDING WITHOUT DIFFICULTY, FOLLOWING SUGGESTIIONS BY SPPECH AND SWALLOW.\nNEURO- INTACT\n PT ABD SOFT, PASSING FLATUS, NO STOOL.\nSKIN- COCCYX IS PINK NOT BROKEN, THORACOTOMY WOUND HEALING NO DRAINAGE, LEG WOUNDHEALING SUTURES INTACT.\n PT SPIKED TO 102.5 RECULTURED, CEFAZOLIN CONTINUES.\nA/P- WITH FREQUENT CPT AND ENCOURAGING PT TO COUGH. KEEP PT MEDICATED ADEQUATELY FOR HIM TO BE COMFORTABLE.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-15 00:00:00.000", "description": "Report", "row_id": 1598778, "text": " Systems review:\n\nCVS: T98.1-99.3 Since spike to 102.0 on eves. HR102-114 ST no ectopy. SBP: 122-159. IV TPN at 85.9cc/h. Mg repleted this am.\n\nNeuro: A&Ox3. MAE. No deficits noted.\n\nSKIN: Incision areas dry and intact. Coccyx slightly reddened, encouraged to stay on sides.\n\nGI: Taking some thickened foods. Difficulty swallowing when on floor and speech recommended no thin liquids. +BS.\n\nGU: u/o=75-270cc/h\n\nResp: Mediastinal CT intact draining straw colored=78cc this shift.\nPt dropped sats on eves to 88%. Using NC 2l and 40%OFM for comfort. sats=98-100%. Breath sounds diminished on left. Pt is trying to cough and deep breathe frequently and is doing better since pain med was changed from MSO4 to Dilaudid PCA.\n\nPain: Pt c/o chest heaviness and pain, Using Dilaudid PCA with some relief but not as comfortable as he would like at times.\n\nplan: OOB to chair today. Repeat CXR.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-02 00:00:00.000", "description": "Report", "row_id": 1598746, "text": "Resp Care\npt weaned and extub per weaning protocol. large Vt's,appeared comfortable on cpap 5. by rn for lg clotlike secretions. extub to cool neb. initially looked good, however with increasing congestion/pain issues. yankauer sxning for yellow to bloody secretions. rhonchi/fremitus left>right. changed to high flow neb with some improvement. marginal resp status. continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-02 00:00:00.000", "description": "Report", "row_id": 1598747, "text": "SICU NPN\nPt extubated this afternoon after tolerating 5PEEP/0PS X2 hours, now with some respiratory distress/difficulty managing secretions.\nROS:\nNeuro: Pt alert and oriented X2-3 after extubation, asking appropriate questions and following commands, able to move all extremities. Pupils 3-4mm and reactive. Pt ordered for 12.5mg morphine Q2 hours ATC, after extubation pt medicated with less due to concerns for airway safety despite standing order.\n\nCardiac: ST 100-130's, moderate ammts PACs noted, 12 lead EKG obtained this AM and reviewed by SICU team. Pt remains sl hypertensive, SBP 140-150's; PA pressures 20/10's, CVP 8-12. PCWP 12-16. C.O. >7, C.I. >4; Hct 28, not transfused per SICU team; extremities warm and well perfused, though puffy and pale. R brachial A-line with moderate ammt serous drainage at site, L PA line and R central line also with some drainage, all dressings changed today. Thoracotomy incison intact. Pt noted to have ? JVD this AM, Dr. in to eval, feels visible pulsation due to slender neck and not JVD. Pt started on lovenox today per ortho, ok'd by neurosurg. Pneumoboots on R leg. Angio site to R groin intact but with copious ammts serous drainage.\n\nResp: See carevue for vent changes and weaning this AM; Pt appeared to be tolerating 5 PEEP/0 PS with adequate ABG, however requiring frequent lavage and suctioning for thick, thick bloody plugs. SICU and trauma teams all notified of sputum and visualized bloody plug sent for culture. Pt extubated this PM, tolerated X3-4 hours, but around 4:30 began to c/o difficulty breathing. Pta lso noted to have very weak and non-productive cough. Pt turned side to side, did not tolerate laying tilted to R side, c/o SOB and CP. Pt unable to cough and clear sputum, NT suctioned many times but unable to clear sputum due to thick consistancy. Pt requiried aggressive pulm care/monitoring, placed on hi- neb and orally suctioned with some improvement, CXR and ABG stable per SICU HO. Lungs coarse and dimished throughout, also noted to have inspiratory/expiratory wheezing. L chest tube with large output, R chest tube with minimal output of serousang drainage. Both dressings changed this PM. Both sides with good fluctuance, (-) crepitus or air leak.\n\nGI: Abd firm, negative BS. OGT d/c'd due to poor positioning, NGT placed with approx 600 cc dk green bilious drainage. Pt NPO per dr. , TPN with pepcid continues.\n\nGU/renal: Pt appears to be starting to autodiurese, u/o >100cc/hr clear yellow urine. lytes checked and repleted PRN.\n\nSkin: Multiple abrasions and ecchymotic areas, draining large ammts serous drainage from all over. Vac to L forearm intact, small blistered area along edge of transparent dressing. Back intact.\n\nID: Low grade temps, no abx.\n\nEndo: SSI coverage\n\nSocial: mother, siblings in to visit and for updates today.\n\nA: Resp difficulty s/p extubation this PM; improving hemodynamics after mullti-trauma;\n\nP: Continue aggressive pulm toilet and moni\n" }, { "category": "Nursing/other", "chartdate": "2107-07-02 00:00:00.000", "description": "Report", "row_id": 1598748, "text": "SICU NPN\n(Continued)\ntoring; consider d/c'ing PA line in AM if pt remains hemodynamically stable; continue with lovenox SC; continue with close pain control monitoring\n" }, { "category": "Nursing/other", "chartdate": "2107-07-03 00:00:00.000", "description": "Report", "row_id": 1598749, "text": "TRAUMA SICU NPN\nO:\nNEURO: ALERT, SOMETIMES LETHARGIC. MAE AND FOLLOWS COMMANDS, ORIENTED X3 AND APPROPRIATE. C/O PAIN AND TO RECEIVE MS04 Q2HRS. C COLLAR REMAINS ON.\n\nCV: TACHYCARDIC, 120'S-130'S WITH OCC APC AND OCC PVC'S. LYTES REPLETED W/ IMPROVEMENT. HTN 140'S-170/90. STABLE FP AND CO/CI. SV02 = 75-79%.\n\nRESP: REMAINS EXTUBATED ON 100% HIGH FLOW FACE MASK (CHANGED FROM FACE TENT) 02SATS 87-92% MOST OF . FOR COPIOUS AMT OF BLOODY, THICK SPUTUM.BRIEF PERIOD W/ 02SAT 96%, THEN DIPPED BACK TO 88-92%.\nLS COARSE W/ INSP/EXP WHEEZES. LEFT SIDE W/ V DISTANT BS.\nCXR DONE SHOWING MINIMAL CHANGE. PT C/O DIFFICULTY BREATHING. LAST ABG\n50/78/7.42/36/6. COUGH IS GETTING STRONGRER.\n\nRENAL: BRISK U/O VIA FOLEY.\n\nGI: NPO, ABD SOFT DISTENDED. BILIOUS DNGE VIA NGT. PT PULLED OWN NGT AT 5AM. ON TPN, NO STOOL.\n\nHEME: HCT 29.\n\nID: TMAX 101.2\n\nSKIN: NO CHANGE. TOTAL BODY EDEMA AND OOZING FROM INCISIONS AND LINES.\n\nSH: GIRLFRIEND IN . MOM ALSO CALLED ASKING APPRORIATE QUESTIONS.\n\nA: RESP DISTRESS, WORKING HARD TO REMAIN EXTUBATED. TACHY AND HTN.\n\nP: TO MONITOR AND PULM TOILET. PAIN CONTROL. NEED REINTUBATION AT SOME POINT\n" }, { "category": "Nursing/other", "chartdate": "2107-07-03 00:00:00.000", "description": "Report", "row_id": 1598750, "text": "Resp Care\npt with increasing resp compromise with hypoxemia,no chest wall movement on left. unable to clear secretions, difficult to suction. pt reintubated and bronched for mod'to lg amts thick bloody secretions on left. able to be maintained on psv mode 10/peep 10/40% with good abg.\n\n" }, { "category": "Nursing/other", "chartdate": "2107-07-03 00:00:00.000", "description": "Report", "row_id": 1598751, "text": "SICU NPN\nS: \"Help me, i can't breathe! dont' let me die!\"\n\nO: Pt very upset and anxious this AM due to c/o SOB and L chest pain. (Pt had been extubated at 1400) See carevue for complete data and assessments.\nROS:\nNeuro: Pt very anxious and upset this AM complaining of difficulties breathing and L sided chest pain. Pt medicated at 8am with standing morphine (12.5mg) dose and became somewhat lethargic, but able to be aroused and complained of pain when awake. Trauma team initially advised d/c'ing morphine and considering narcan dose to waken pt up and stimulate coughing, however plan changed back to the ATC morphine (decreased to 5mg Q2 hours standing) per dr. . C-collar d/c'd this AM by dr. , however replaced per dr. . Pt intubated at 9:15 AM, placed on low dose propofol for comfort and sedation. Pt also continues on 5mg morphine Q2 hours ATC, appears comfortable and tolerates activity/turning/suctioning. Placement of epidural cath considered today for better pain management, will reevaluate need in AM. Pupils 2-4mm and briskly reactive, pt easily through sedation, moves all extremities and following commands, nodding yes and no appropriately.\n\nCardiac: Initially this AM, pt tachycardic to 140's, hypertensive with resp distress episode; after intubation, pt initially remained extremely hypertensive 200/100's and tachycardic to 150's, medicated with 10mg morphine IV push with some results. pt remained tachycardic throughout the day, occasional PVCs and PACs. BP stablized this PM with SBP 120-150's. PA line d/c'd, changed introducer over a wire to triple lumen this PM, placement confirmed by CXR. R subclavian d/c'd this PM also. Extremities warm and well perfused, pulses easily palpable. Pneumoboots, lovenox for DVT prophylaxis. Hct down to 26.6 from 27.7, will recheck with AM labs.\n\nResp: Pt c/o difficulty breathing this AM, stating that he \"Couldnt' breathe\" and had alot of L sided chest pain. O2 sats to 84% with SVO2 of 47 this AM, PAO2 of 58. Pt also noted to have very minimal movement of L side of chest. Pt intubated at 9:15 AM, then suctioned for copious ammts thick, old bloody sputum. Pt also bronched this AM for large ammts old blood and plugs. Sats stablized after intubation and aggressive suctioning/chest PT. Bilateral chest tubes with serosang drainage, L>R, both without crepitus at site or air leaks. Pt nodding that it is easier to breath with vent. Pt remains on PSV with adequate rate, volumes and ABGs, sats 99-100%.\n\nGI: Abd firm, no BS noted. OGT replaced after intubation, draining mod ammts green bile. TF initially ordered this AM but held per trauma team. TPN continues, pepcid in TPN.\n\nGU/renal: Good u/o via foley cath, urine appears concentrated, ?Slightly ichteric. Lytes repleted PRN.\n\nID: Tmax 102.1, pan cultured and given tylenol.\n\nEndo: SSI coverage, see flowsheet for data.\n\nSkin: Multiple abrasions/lacs to extremeties and torso; Pt c/o tightness with ace\n" }, { "category": "Nursing/other", "chartdate": "2107-07-03 00:00:00.000", "description": "Report", "row_id": 1598752, "text": "SICU NPN\n(Continued)\nwrap to L leg, ace taken down and left off temporarily. Incision to L knee draining moderate ammt bloody drianage, multiple pin sites/lacs with staples. Thoracotomy incision intact with staples, bypass incision also intact with staples.\n\nSocial: Pt's both in today to visit with pt, updated on pt's care and condition. also able to speak with drs. and from SICU team.\n\nA: Improved respiratory status s/p intubation, bronch and pulmonary toilet; improved comfort with intubation and lower morphine dose;\n\nP: Keep pt intubated and comfortable overnight; consider weaning trial again in AM based on pt's appearence, labs, o2 sats and assessment. Continue NPO/OGT and TPN; follow culture data, WBC and temp curve; Consider epidural placement in AM for pain control\n" }, { "category": "Nursing/other", "chartdate": "2107-06-30 00:00:00.000", "description": "Report", "row_id": 1598741, "text": "NPN (0700-1530) Review of Systems:\n\nNeuro: Pt to voice, opens eyes, follows commands and nodds head appropriately. Pt c/o pain all over most of time, pt medicated with 10mg IV Q2hr c effect. C spine precautions maintained. PERRL. MAE, though moves L arm and R leg > R arm and L leg 2' injuries.\n\nCV: NSR/ST c hr=90-100, no ectopy. SBP=120-150. PA line c pap=30-40/20s, CO=, PCWP=19-20, CVP=14-16, SvO2=75-80%. Color pink, palpable pulse all extremities, +CMS all extremities. +peripheral edema. Venodyne RLE.\n\nResp: LS clear and dm at bases. IMV decreased to 400x14 and team willing to tol higher PCO2 in order to reduce barotrauma per team. After changes, ABG more acidotic c ph=7.34, PCO2=55, PaO2=84, BXS+1 and HCO3=31 and team aware. SaO2=90-93% on 50% Fio2 and PaO2=70-80s c that O2 saturation and SICU team aware. Pt suctioned for sm amt of blood tinged secretions. R&L CT intact and draining mod amt ss drainage (see careview I&O), no air leaks, site D&I. Consider bronch if secretions increase.+gag, +cough.\n\nGI: Abd distended, though unchanged this shift. Team aware. Plan to continue Impact with fiber at 10cc/hr s advancing to goal. Residuals Q4 hours. No BM. Carafate continues.\n\nGU; Indwelling foley intact and draining clear yellow urine, UO=20-100cc/hr. IVF bolus given x1 for low UO. Electrolytes wnl.\n\nHeme: Am HCt=30.1, continue to follow labs Qd.\n\nID: Tmax=100s. AM WBC=7.5.\n\nEndo: BG=180 at 1200, pt covered c 5u regular insulin.\n\nSkin: Skin warm and moist to touch, pt diaphorteic at times though core temp=100s. Pt turned and repositioned for comfort. Multiple abrasions healing and OTA.\n\nSOC: Mother called this am and plans to be in this afternoon.\n\nA/P: Continue full support as above. Continue to support resp status. Plan for OR tomorrow for washout of LLE and removal of ex fix.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-06-30 00:00:00.000", "description": "Report", "row_id": 1598742, "text": "SOCIAL WORK NOTE:\nMet with pt's mother, , today to introduce self in person. She was interacting with pt and reported that this was the first time she was able to do so. She was very happy about it and hopes that pt's condition will steadily improve. This SW remains available as needed. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2107-07-01 00:00:00.000", "description": "Report", "row_id": 1598743, "text": "T/SICU NPN 7P->7A:\n\nREVIEW OF SYSTEMS:\n\nNEURO: NEURO EXAM STABLE/UNCHANGED: PT OPENS EYES, F/C'S, ATTEMPTS TO MOUTH WORDS/COMMUNICATE, ABLE TO MAE'S, NODDS HEAD TO QUESTIONS APPROPRIATELY. CONTINUES TO [ACKNOWLEDGE] PAIN [ALL OVER] - MSO4 10MG/Q2HR W/(+)EFFECT - PT TOLERATING TURNS/PROCEDURES BETTER. SEVERAL EPISODES OF AGITATION ->UNCLEAR IF PAIN IS THE TRIGGER OR IF IT IS R/T PTS BASELINE; GIRLFRIEND SPOKE WITH THIS RN LAST STATING PT IS \"HIGH STRUNG\" \"ANXIOUS\" AS WELL AS \"ALWAYS ON THE GO...\" AT BASELINE. EPISODES OF AGITATION OFTEN CAUSE PT TO DESATURATE TO 80'S (SVO2 DOWN TO 56-60'S), W/ASSOCIATED HTN AND TACHYCARDIA.\n\nCV: HR 80-90'S, SBP 130-140'S, CVP 9-16, CO 9.07 CI 4.75, PAP'S 30-40'S/20'S, PAWP 17. PT W/1 EPISODE V TACH (6BEAT RUN) @0530 - SICU HO AWARE - NO OTHER ECTOPY NOTED THROUGHOUT . SKIN PALE PINK/WARM/DRY. PULSES EASILY PALPABLE IN ALL EXTREMITIES W/ CAP REFILL <3 SECONDS. (+) PERIPHERAL EDEMA.\n\nHEME: HCT 29.7(30.7), PLT 42(45), INR 1.2(1.3).\n\nRESP: LUNG SOUNDS CLEAR IN R UPPER FIELD, COARSE THROUGHOUT OTHER LOBES. LAVAGE/SXN FOR SM->MOD AMTS THICK/BLOODY SECRETIONS. VENT CURRENTLY ON SIMV 500X14, 50%, PEEP 12.5/PSV 5: SATS 95-99%, SVO2 72-78. PT OCCASIONALLY VENT BY SEVERAL BREATHS. NP. PT DESATURATES W/AGITATION/ESCALATES WHEN IN PAIN - RECOVERS SLOWLY TO CURRENT BASELINE. B/L CT'S TO SXN DRAINING SERO/SANG FLUID, L>R, NO AIR LEAKS ->PER C/T MD, TUBES CAN BE D/C'D AFTER DRAINAGE DECREASES <150CC OVER 8HR PERIOD. SEE CAREVIEW FOR ABG DATA.\n\nGI: ABD DISTENDED W/HYPOACTIVE BS, NO BM OR EMESIS. TF IMPACT W/FIBER INCREASED TO 20CC/HR - NO RESIDUALS NOTED. REGLAN/CARAFATE GIVEN AS ORDERED. TPN INFUSING AS ORDERED.\n\nGU: 20MG LASIX GIVEN W/BRISK EFFECT - LG VOLUME OUT: CLEAR/YELLOW. HOURLY AVERAGE ~45CC/HR S/P EFFECTS OF LASIX.\n\nENDO: GLUCOSE 182->134->120. SSRI COVERAGE AS ORDERED. INSULIN ALSO IN TPN.\n\nID: TMAX 100.0->99.5. NO ABX ORDERED AT THIS TIME.\n\nSKIN: LLE DSG CHANGED - SUTURES INTACT - DISTAL PIN SITES W/ SM AMT SERO/SANG DRAINAGE. SUTURE/PIN SITES WNL/PINK. SCANT DRAINAGE FROM LUE WOUND - VAC DSG INTACT. RUE IN SPLINT - BRUSING UNCHANGED. THORACOTOMY SITE WNL/INTACT. L CT SITE W/ SM AMT SERO/SANG DRAINAGE - R CT SITE BENIGN. BACK/BUTTOCKS INTACT. BENADRYL GIVEN FOR PURITIS W/(+) EFFECT.\n\nSOCIAL: GIRLFRIEND [] VISITED FOR SEVERAL HOURS LAST EVENING.\n\nA/P: HEMODYNAMICALLY STABLE, PAIN FAIRLY WELL CONTROLLED, LABILE RESP STATUS. CONTINUE PER PLAN OF CARE: MONITOR SYSTEMS/LABS FOR CHANGES - REPLETE LYTES AS NEEDED. AGGRESSIVE PULMONARY HYGEINE, PAIN MGT, GLUCOSE MONITORING. F/U W/TEAM RE: CHANGING OGT TO POST PYLORIC TUBE. ALSO (?) NPO IF PT TO RETURN TO OR LATER TODAY FOR WASH-OUT OF LLE. LIKELY CTS TODAY OF LLE/LUE. FULL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-01 00:00:00.000", "description": "Report", "row_id": 1598744, "text": "SICU NPN\nPt remained hemodynamically stable today while awaiting OR for ORIF/plating of L tibial plateau fractures.\nbrief ROS:\nNeuro: pt waking very easily, nodding yes and no and mouthing out words around the ETT appropriately; Pt medicated with 10mg MSO4 Q2hours ATC for pain/agitation control, however pt still appeared anxious. Morphine dose increased to 12.5mg Q2hours per SICU team, no ativan or propofol at this time per trauma/sicu teams. Pt continues to wake easily, moving all extrmemites, nods no mostly to pain but yes to discomfort with breathing and anxiety. Pupils 2-4mm and briskly reactive bilaterally.\n\nCardiac: SBP 140-160's most of morning with peaks into the 170's when awake and stimulated. Dr. and sicu team notfied and aaware, extra dose of morphine given without improvement. Spoke with dr. regarding elevated BP and tachycardia (90-100's), addressed concerns due to recent aortic surgery/graft. Per teams, pt appears stable at this time and will continue to monitor current hemodynamics. C.O. >7 with index > 3.5; PCWP 22 in early AM, down to 16 this PM, CVP 6-16. PA pressures 20/10's. R brachial A-line slightly positional with some serosang drainage at site, both subclavial central lines with scant serosang drainage also. R groin angio site with moderate ammt serosang drainage, DSD changed. Extremities warm, perfused, slightly difficult to palpate pulses due to swelling but easily dopplerable. Teams aware of low plateltes, hct below 30 pre-op, clot sent to BB with type and cross for 4 U PRBCs and 1 pack platelets reserved. New PA line tubing/flush pack up this AM. L thoracotomy incision intact with staples, DSD changed today.\n\nResp: Pt changed over to PSV, 12.5 PEEP and 5PS with adequate sats, volumes and ABG. Bilateral chest tubes remain to suction, both dressings changed X2 due to saturation from serosang drainage at sites. Both chest tubes with good fluctuance, no air leak and no crepitus. Lungs clear, diminshed at bilateral bases. Pt suctioned Q3-4 hours for thick, bloody sputum. No bronchoscopy this PM per dr. .\n\nGI: Abd distended, fairly firm, very hypoactive BS throughout. Pt NPO per dr. , no dulcolox also. Pt continues on TPN for nutrition. Carafate, reglan for GI prophylaxis.\n\nGU/renal: Good u/o via foley cathter; lytes repleted PRN.\n\nID: Afebrile, Tmax 99.\n\nEndo: Insulin in TPN, no additional coverage required.\n\nSocial: mother in to visit, updated on plan for OR this afternoon.\n\nSkin: Pt oozing large ammts serosang fluid from everywhere. Vac to LLarm intact, ex-fix to L leg with ace wrap; splint to RLA. Pt brought to CT scan this AM for images of R wrist, L leg; results pending.\n\nA: Improving hemodynamics/pulmonary function s/p motorcycle accident.\n\nP: Continue to monitor vitals, labs, I+Os; continue to try and wean vent support; re-evaluate pain control/sedation on return from OR\n" }, { "category": "Nursing/other", "chartdate": "2107-07-02 00:00:00.000", "description": "Report", "row_id": 1598745, "text": "T-SICU NSG NOTE:\nPT ARRIVED FROM OR S/P ORIF OF L TIBIAL PLATEAU FX, AND SPLINT TO L. ARM.\n\nNEURO- SEDATED WITH MSO4, AND ALSO RECEIVED 2 DOSES OF ATIVAN AND SEV. HRS OF PROPOFOL GTT. PT NOW OPENS EYES TO SPEECH, MAE'S, FOLLOWS COMMANDS, PERRLA 3MM, +GAG AND STRONG COUGH.\n\nRESP- SUX FOR SM AMTS THICK BRB. BS CLEAR AND DIMINISHED IN BASES, MAINTAINED ON SIMV MOST OF THE NIGHT AND CHANGING TO PSV IN THE AM. ABG W/ MET ALK. SAO2 97-99% DROPPED TO 87% X1 WITH L SIDE DOWN.\n\nCVS-TACHY 130'S NST NO ECTOPY, HYPERTENSIVE SBP^200 RECEIVED SEVERAL BOLUSES OF 12.5MG MSO4, AND ATIVAN. FP'S WNL, CO 7.9-9.8, SEE FLOWSHEET FOR ALL DETAILS. LOW GR TEMP, K,+ CA REPLETED.\n\nGI-RESTARTED TF OF IMPACT W/ FIBER @20CC/HR AND TPN ., ABD SOFT, NO BS, ON REGLAN.\n\nGU- STRONG UO POST OP.\n\nSKIN- DRAINING LG AMTS SEROSANG DRAINAGE FROM CT SITES, THOROCOTOMY INCISION W/ STAPLES INTACT AND DRAINING SEROUS, MULT BRUISING AND ABRASIONS.\n\nA: TACHY AND HYPERTENSIVE MOST OF THE NIGHT, MD AWARE\n\nP: MONITOR VS PER ROUTINE, FOLLOW LABS AND REPLETE LYTES, MAINTAIN PULM HYGIENE,MED FOR PAIN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-07-04 00:00:00.000", "description": "Report", "row_id": 1598758, "text": "NPN: Review of Systems\nNeuro: Pt awake. Follows commands. Communicates by mouthing words, writing and using gestures. Calm most of the time, but occasionally has episodes of increased anxiety which he has been relieved by reassurance.\n\nResp: . on PS of 10 and 5 PEEP. Sao2=98-100%. RR=20s. Pt has occasional epsiodes where he feels like he can't breath, as noted above he has calmed w/ talking. Sxning white secretions. Vest fluoroscopy done to evaluate diaphragm.\n\nCV: ST. Rare PVC. BP=159/85, but if anxious SBP can go up to 190s.\nPlease see flowsheet or further data and assessment. DP and PT pulses palpable bilaterally.\n\nGI: TPN infusing as ordered. TF on hold due to residual >100. Abdomen is soft. (+) bowel sounds.\n\nGU: Foley to gravity. Brisk UO.\n\nID: Temp=100.1. Started on zosyn.\n\nheme: HCT=24.1 from 24.6.\n\nSkin: Thoracotomy site clean w/ approximated edges. No pressure wounds on backside.\n\nComfort:Pt c/o back pain all over and chest discomfort at CT sites. Medicated w/ 5mg Morphine sulfate ATC w/ good effect.\n\nA: Hemodynamics stable. Occasional episodes of anxiety which sometimes correllate to increased pain. Good relief w/ morphine and reassurance.\n\nP: F/U w/ results from fluoroscopy. Monitor as ordered. Check Tube feed residual to evaluate if it can be restarted.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-05 00:00:00.000", "description": "Report", "row_id": 1598759, "text": "Resp Care Note:\n\nPt intub on mech vent as per Carevue. Lung sounds sl coarse suct sm bldy sput. Pt alert and responds appropriately. No changes made overnoc. PSV wean.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-05 00:00:00.000", "description": "Report", "row_id": 1598760, "text": "TSICU NPN 11p-7a\nS/O-\nNeuro/pain- Pt alert and appropriate, MAE's w/in limitations of his injuries. C/O much sharp constant pain particularly around CT insertion sites and upper back and scapula pain, at worst pain reported as a '9' on a scale of 0-10 w/ 10 being the worst. Med w/ Mso4 5mg q 2hrs w/ 2 PRN doses given as well over the course of the shift. W/ PRN med pt able to doze off for short periods. Pt does not tolerate turning and /or CPM machine well.\n\nCV- con't tachycardic w/ HR 105-120, BP stable at 130-150's over70-80.\nCVP 10-12. Hct down to 22.9 from 24.1, HO aware, no transfusions at this time, pt con't w/ brisk u/o, urine quite bilious looking, bright in color. Potassium and mag repleted.\n\n pt on PSV of 10 and 5 of PEEP overnoc w/ RR from 18-11 and TV's from 550-850 at rest, when awake able to take TV of 1.1liter. BS's diminished on left and at right base, pt suctioned for mod amt thick blood tinged sputum. Left CT w/ small air leak, draining serosang fluid, right CT w/ minimal drainage.\n\n pt w/ flat abd, slightly firm, hypo active bowel sounds, attempting TF's yet held for aspirates of 100cc's at midnoc, restarted at 4a at 30cc's /hr. No BM this shift, con't on reglan. Con't on TPN for now as well.\n\nGU- uring quite bilious / colored as above. Brisk u/o throughout the shift.\n\nendo- BS slightly increased this AM requiring coverage per scale.\n\nID- t max 100.1, WBC down this AM, con't on zosyn, Positive blood cultures called back from a line on , HO aware.\n\northo/plastics- pt w/ CPM on left leg till 1:30 A then removed for pt to sleep, vacc dsg to left arm intact.\n\nA/P - con't to monitor closely, pain management and pulmonary toilet as ordered. Pt awaiting vac change .\nCon't to increased activity as tolerated, pt consult. ? ducolox for bowel if no bm soon.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-06 00:00:00.000", "description": "Report", "row_id": 1598767, "text": "SICU NPN\nPt more awake today, alert and oriented X3, moving all extremities and following commands. Lungs coarse, pt able to cough and clear sputum independently. R sided chest tube placed to water seal. Pt noted to be jaundiced with ichteric urine, galbladder u/s performed at bedside today. Unable to get pt OOB to chair per dr. due to c-collar, though neck x-ray/ct scan shows no bony injury. plan to take pt to x-ray for flex/extention films this PM. Pt started on sips clears and tolerating well. Plan to keep pt in ICU for close pulmonary hygiene/resp monitoring. See carevue for skin assessment and care.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-07 00:00:00.000", "description": "Report", "row_id": 1598768, "text": "T/SICU NPN 2300->0700:\n\n* * * * * * * TRANSFER NOTE * * * * * * *\n\nPT IS A 22 Y.O. MALE ADMITTED S/P MVA: FIRST TIME OPERATOR OF MOTORCYCLE IN COLLISION W/MOTOR VEHICLE. PT WEARING HELMET - NO LOC @ SCENE. INTUBATED/SEDATED S/P INCREASED PAIN W/DECREASED SATS. PRESENTS TO W/ INJURIES AS FOLLOWS:\n\n DESCENDING AORTIC DISECTION\n L TIBIAL PLATEAU FX\n LUE DEGLOVING INJURY\n PULMONARY CONTUSIONS\n R SCAPULAR FX\n RUE WRIST FX - SPLINTED\n PARANCHYMAL BLEED\n ABRASIONS\n\nPT TO OR FOR AORTIC DISECTION REPAIR, I&D & EX.FIX. OF LLE, I&D OF LUE W/WOUND VAC PLACEMENT.\n\nPT RETURNED TO OR FOR WASHOUT OF LLE AND ROD PLACEMENT - WOUND VAC TO LUE D/C'D-> DSD.\n\nSICU COURSE EVENTFUL FOR OXYGENATION ISSUES: B/L CT'S TO SXN FOR EFFUSIONS, PNEUMO/HEMO THORAX. EXTUBATED/RE-INTUBATED -> R/T DOE/SOB AND INCREASED SECRETIONS. SUCCESSFULLY EXTUBATED .\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT/ORIENTED/APPROPRIATE - COMPLIANT W/CARE REGIMEN. MAE'S, F/C'S. STRONG COUGH/GAG EFFORT. PERRLA - 3MM/BRISK. EPIDURAL PLACED FOR PAIN R/T CHRONIC BACK PAIN ISSUES, AS WELL AS CURRENT RIB/SHOULDER/LEG FX'S. CURRENTLY @ 12ML/HR, SENSORY BLOCK @T4. INSERTION SITE WNL - BENIGN. GIVEN PRN MSO4 FOR MUSCULOSKELETAL PAIN W/ (+) EFFECT - RESTING COMFORTABLY. BENARYL FOR PURITUS W/(+)RELIEF OF SX. CERVICAL COLLAR ON UNTIL C-SPINE CLEARED.\n\nCV: HR ST 100-110'S, SBP 130-140'S. SKIN ICTERIC, WARM/DRY. PULSES PALPABLE - (+)CSM TO DISTAL EXTREMITIES: CAP REFILL <3SECONDS.\nLYTES REPLETED.\n\nHEME: HCT 29.5(27.8), PLT 345(276)\n\nRESP: LUNG SOUNDS CLEAR IN UPPER FIELDS, DIMINISHED @B/S BASES. STRONG/PRODUCTIVE COUGH - ABLE TO RAISE SECRETIONS FOR ORAL SXN: THICK/BLD TINGED. SATS 95-97% ON 50% COOL NEB FACE TENT. DENIES SOB/DOE. L POSTERIOR CT TO SXN DRAINING SERO/SANG FLUID, SM AIR LEAK NOTED. R ANTERIOR CT TO WATER SEAL W/SCANT SERO/SANG OUTPUT, NO LEAK. INSERTION SITES WNL.\n\nGI: ABD SOFT, NT/ND W/(+)BS/RF, NO BM. DENIES N/V - TOLERATING CLEAR LIQUIDS. TPN INFUSING AS ORDERED.\n\nGU: FOLEY CATHETER PATENT DRAINING ADEQUATE VOLUME OF CLEAR/AMBER COLORED URINE.\n\nENDO: GLUCOSE LEVELS <150 - COVERED PER S/S: INSULIN ALSO IN TPN.\n\nID: TMAX 100.7, WBC 10.5(9.7) - ABX GIVEN AS ORDERED.\n\nSKIN: BACK/BUTTOCKS INTACT. R ARM IN SPLINT W/(+)BRUISING. L ARM W/DSD TO DEGLOVING INJURY - PLASTICS TEAM TO CONSULT FOR FUTHER TX. LLE W/STAPLES INTACT - SCANT DRAINAGE NOTED. CT INSERTION SITES WNL.\n\nACTIVITY: PT ABLE TO PARTICIPATE W/ ADL'S W/ ASSIST - TOLERATES TURNS WELL.\n\nA/P: STABLE, PAIN ISSUES WELL CONTROLLED - TOLERATING DIET ADVANCE - LIKELY TXFER TO FLOOR WHEN BED AVAILABLE. CONTINUE PER PLAN OF CARE - FULL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 1598769, "text": "SICU Re-Admit note\nPt is a 23 yr old male who was admitted to SICU on after a motorcycle accident. Pt's admitting injuries consisted of a degloving injury to his left lower arm, left tibial plateau fracture, right wrist fracture, punctate intraparenchymal hemmorhages and a descending aortic injury. Pt was brought emergently to the OR on for repair of his aortic injury with graft placement, washout and vac placement to L arm and ex-fix placement to L leg. Pt returned to the OR on for tibial plateau plating. Pt weaned and extubated on , reintubated on due to difficulty managing secretions. Pt extubated again on and did well. Pt transferred to floor on in stable condition.\n\non , pt noted to have an episode of desaturation down to 86% after vomiting, sats only up to 91% initially with 2L O2. Pt brought to CTA to r/o PE, abd CT to r/o obstruction (related to vomiting/nausea), noted to have moderate size pericardial effusion. Pt transferred to SICU, had TTE on admission to evaluate effusion. Per cardiology team, effusion noted to be quite large with complete RA collapse and significant RV collapse consistant with tamponade. Pt taken emergently to cath lab, where 620 cc of bloody fluid removed from pericardium and pericardial drain left in place. Of note, pt had C.O. 3.21 with C.I. 1.68 pre-procedure, and C.O. 6.96 with C.I. 3.57 post drainage. Please see procedure note for vitals and other assessment throughout drainage. Pt transferred back to the SICU around 11:15 pm in stable condition for close hemodynamic monitoring.\nROS:\nNeuro: Pt slightly anxious, alert and oriented X3. Pt able to MAE with good strengh but requires encouragement to do so. Pt using PCA morphine appropriately for pain control.\n\nResp: Lungs clear, dimished at bilateral bases L>R. Pt able to cough and clear small ammts thick bloody tinged sputum. L sided chest tube removed with small effusion noted on CXR afterwards.\n\nCardiac: Sinus tach on admission up to 130's on admission, rare ectopy noted. R groin sheaths removed on readmission from cath lab, site benign with DSD. Pulses weakly palpable to bilateral lower extremities. Pericardial drain site intact, drain to gravity drainage. Drain flushed with 2cc of 10U/cc heparin flush solution Q2hours. BP stable, SBP 100-110's pre-procedure, up to 150 post-cath. L subclavial TLC site intact, CVP 12 pre-cath, 2 post cath. Plan to hold 4AM dose of lovenox due to drain in place. Pneumoots on. Pt noted to have better color post-procere, remains slightly jaundiced but checks pinker.\n\nGI: NPO, sips clears. Feeding tube d/c'd on admission per dr. . Abd soft, BS noted throughout. TPN held per MDs.\n\nGU/renal: Pt voiding in small ammts via urinal.\n\nSkin: See carevue for thorough assessment. L thoracotomy incision intact with staples, slightly pink at edges. Ace wrap to LUE, ace with splint to RUE. L leg incisions intact with steri-strips and staples. Pt noted to be slighlty jaundiced but much\n" }, { "category": "Nursing/other", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 1598770, "text": "SICU Re-Admit note\n(Continued)\nmore pink after procedure today.\n\nEndo: No issues\n\nID: Pericardial fluid sent for culture; kefzol Q8 hours while pericardial drain in place.\n\nSocial: mother and girlfriend both in to visit with pt pre- and post procedure. Cardiology and trauma both in and spoke with pt's mother.\n\nA: Stable s/p pericardial drainage with drain in place.\n\nPlan: Continue with close hemodynamic monitoring; plan to keep pericardial drain in place for now,flushing Q2hours; keep NPO/fluid restrictions with only sips of clears due to hyponatremia; continue with current management.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 1598771, "text": "SICU NPN ADDENDUM\nPt with several episodes overnight of desaturation to the 80's with increased ectopy at the same time, little response to increased FIO2. Pt also noted to have severely dimished breath sounds on L side when sats down. CXR showed ?effusion but no pneumo. Sats finally back up after aggressive pulmonary toilet, coughing and deep breathing. Lung sounds to L side also improved after this. Pt continues now on 70% FIO2 face tent to help humidify and loosen sputum, continues to require encouragement to cough and deep breathe.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 1598772, "text": "NURSING NOTE: 7AM -7PM\nNeuro: Awake alert and oriented X3, slightly anxious, pleasant and cooperative. MAE with good strength. Using PCA MSO4 well, denies pain. C/V: SR to ST rate 86-120, with episodes of frequent PVC's. Pulses palpable to lower extremities. Pericardial drain site intact flushed with 20 units (2CC) of heparin q 2 hours. Draining seroussang drainage 75cc total at 11am. Decreased drainage from 11am-3pm. Plan to increase flushes. RESP: O2 on at 70% Facetent decreased to 35% Facetent . Lung sounds clear with decreased bases. Frequent deep breathing and IS done raises mod amts thick yellow/tan secretions. Dsg intact on Left chest where Chest tube removed yesterday.O2 Sat 97-100% SKIN: Skin color pale, warm and dry. Staples intact at LT thoracotomy site and Lt Leg. Ace wrap to LUE, Ace with splint to RLE. GI: NPO except sips, tol well. Requesting to eat. Abd soft, nontender BS present. Swollowing and speech eval done at bedside with further studies done under flouro in radiology. Results pending. GU: Voided X1 400 cc out clear yellow urine. Urine needed for labs. SOCIAL: Mother and friend into visit, undate given. PLAN: Increase Pericardial flushes\n" }, { "category": "Nursing/other", "chartdate": "2107-07-14 00:00:00.000", "description": "Report", "row_id": 1598775, "text": "SOCIAL WORK NOTE:\nPt known to this SW has returned to T-SICU due to pericardial effusion. I met with his mother, , today briefly to offer continued support. She is very hopeful about pt's condition and hopes that he will not need to be on the ICU much longer. This SW is available as needed for support. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2107-07-14 00:00:00.000", "description": "Report", "row_id": 1598776, "text": "T-SICU NURSING PROGRESS NOTE\nPT RETURNED FROM OR S/P PERICARDIAL WINDOW, TOLERATED PROCEDURE WELL. UPON RETURN FROM OR, PT HYPERTENSIVE TO 170S/SYSTOLIC AND TACHYCARDIC 120S. RECEIVED FENTANYL AND PROPOFOL INCREASED WITH SOME IMPROVEMENT IN HR, RECEIVED ANOTHER 100MCG FENTANYL APPROX 30 MINUTES LATER WITH FAIR EFFECT. AT 9:30AM, PT TO 92%, ABG DONE REVEALED PA02 OF 71. CXR DONE, REVEALED LUL COLLAPSE. PT C/O FEELING THAT IT WAS DIFFICULT TO BREATHE, INCREASED PAIN ON INSPIRATION. TEAM IN TO EVALUATE, 10MG IV MS04 GIVEN AND RECRUITMENT MANEUVERS DONE, PA02 IMPROVED TO 154 (FROM 74), CXR REPEATED AT 2:30PM, RESULTS PENDING.\n\nCURRENT REVIEW OF SYSTEMS:\n\nNEURO: TO NAME, FOLLOWING COMMANDS, MAE'S. PT CONTINUES TO C/O PAIN WITH BREATHING, USING PCA APPROPRIATELY, RECEIVED ONE TIME EXTRA DOSE OF MS04 AT 2:30PM WITH FAIR EFFECT. PROPOFOL WEANED TO OFF.\n\nCV: HR 110S-120S, SINUS TACH, NO ECTOPY NOTED. BP 140/60S WHILE SLEEPING, UP TO 150S-160S/60S WHEN AWAKE. SICU TEAM AWARE. SKIN SLIGHTLY PALE, WARM, (+)EASILY PALPABLE PULSES. MEDIASTINAL CHEST TUBES TO SXN, DRAINED 108CC SEROSANG SINCE 9A.\n\nRESP: BREATH SOUNDS CLEAR ON RIGHT, DIMINISHED ON THE LEFT. SUCTIONED FOR SMALL TO MOD AMT OF THICK TAN SECRETIONS. SATS 99-100%.\n\nGI: ABD SOFT, (+) BOWEL SOUNDS. NPO, CONTINUES ON TPN\n\nHEME: HCT 25 DURING OR, REPEAT TO BE SENT AT 4PM.\n\nID: AFEBRILE, NO ABX\n\nSKIN: COCCYX SLIGHTLY PINK, REPOSITIONED ON LEFT SIDE. OTHERWISE NO NEW ISSUES\n\nSOCIAL: MOTHER IN TO VISIT, UPDATED BY SICU TEAM ON PT'S CONDITION.\n\nA: S/P PERICARDIAL WINDOW, MORE HYPERTENSIVE AND TACHYCARDIC, NEW LUL COLLAPSE\n\nP: MONITOR RESP STATUS CLOSELY, ? WEAN AND EXTUBATE THIS EVENING, PAIN MANAGEMENT, CONTINUE WITH CURRENT PLAN\n" }, { "category": "Nursing/other", "chartdate": "2107-07-15 00:00:00.000", "description": "Report", "row_id": 1598779, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: ALERT. COOPERATIVE. USING HYDROMORPHINE PCA FOR\n PAIN WITH FAIR RELIEF. MOTRIN OFFERED AND DECLINED.\n\n\nCV: HR AND BP STABLE. MG 1.6 AND REPLETED.\n CA 1.15 CARDIAC ECHO DONE.\n\nRESP: ON FACE TENT WITH GOOD SATS. USING INCENTIVE\n SPIROMETER Q1-2 HOURS. YANKEUR BY SELF AND\n RAISING THICK WHITE SECRETIONS.\n LAST CXR SHOWS IMPROVEMENT IN LEFT WHITE OUT.\n 2 MEDIAST CHEST TUBES TO SUCTION WITH SCANT\n OUT.\n\nRENAL: NA 131 K 4.1 CL 98 CO2 26 BUN 11 CREAT 0.3\n GOOD UO...URINE CLOUDY/SEDIMENT.\n\nGI: TPN WITH LIPIDS/INSULIN. SOFT DIET/ THICKENED\n FLUIDS. NO BM TODAY. ABD SOFT. PHOS 3.4\n SPEECH/SWALLOW FOLLOW UP... ASPIRATION\n PRECAUTIONS. IV PROTONIX.\n\nHEME: HCT 28.7 AFTER ONE RBC YESTERDAY.\n BOOTS/SC HEPARIN.\n\nENDO: BS 134.\n\nID: LOW GRADE TEMPS AFTER TYLENOL.\n WBC 14.2 IV KEFZOL.\n\nSKIN: SEE FLOWSHEET. ? WORSENING RED COCCYX..?\n ?? FIRST STEP MATTRESS NEEDED.\n\nSOCIAL: MOM VISITED IN AM.\n\nA: STABLE S/P PERICARDIAL WINDOW.\nP: RESP CARE. TRANSFER TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-15 00:00:00.000", "description": "Report", "row_id": 1598780, "text": "SOCIAL WORK NOTE:\nMet with pt this a.m. to offer continued support. Pt is in remarkably good spirits and remains very pleasant. This SW is available as needed. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2107-07-16 00:00:00.000", "description": "Report", "row_id": 1598781, "text": "TSICU\nNEURO: A&OX3. Pleasant, Appropriate. MAE equal strength/resistance throughout.\n\nCV: HR st 100's. BP 150's/80's. Mediastinal Chest tubes to LWS intact without crepitus or leak with minimal amts of sanginous output.\n\nRESP: Lung sounds clear dimished at bases. Patient compliant with IS. Uses splinting pillow during coughing and deep breathing. SATs 95-100%. Cough productive with moderate amts of thick tan output.\n\nGI:Abd soft nontender nondistended bowel sounds present. Tol thick liquid diet. TPN. Carafate.\n\nGU: u/o 100cc hr yellow sediment.\n\nSKIN: With impaired areas. L thoracotomy site staples approximated OTA without drainage minimal erythema. L lower leg staples intact OTA no erythema. L arm with ace wrap from old degloving injury site intact without drainage or tenderness. Coccyx warm reddened. Turned frequently. Mediastinal CT site intact without drainage.\n\nID: Tmax 99.6 Kefzol.\n\nHEME: Heparin.\n\nSOCIAL: Supportive family. Followed by social work.\n\nA/P: with pulmonary tolieting. Transfer to floor when telemetry bed available.\n" }, { "category": "Nursing/other", "chartdate": "2107-06-28 00:00:00.000", "description": "Report", "row_id": 1598735, "text": "SOCIAL WORK NOTE:\n\nNew trauam pt on T-SICU. Pt is a 23 year old single man who lives downstairs from his , and , in . Pt is s/p helmeted motorcycle accident. He works part-time at CVS and is a student at Community College. He has an older brother and sister, (35) and (34). mother was in this afternoon for a brief visit. This SW was not able to meet with her at that time but I called her at home and spoke with her there ().\n\n mother used to work as a unit coordinator in an ER and pt's father used to be a police officer. mother reports that they are both used to seeing situations like this but was able to state how different it is when it is one of your own children. She states that pt has an on-again, off-again girlfriend named who visited last night and will be visiting with again later this evening. mother denies that pt has psychiatric history and said that to her knowledge, he smokes pot occasionally. mother also reports that pt's father is feeling angry with pt because he hadn't told them that he had purchased a motorcycle and that he got into an accident the first time he took it out. father was a motorcycle cop and would have been willing to help teach his son how to ride the motorcycle safely.\n\nThis SW will remain involved to offer continued support and will try to meet family in person tomorrow. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2107-06-28 00:00:00.000", "description": "Report", "row_id": 1598736, "text": "TSICU ADMISSION NOTE\n 1700: 23 YO MALE S/P MOTORCYCLE VS TRUCK\n-LOC @ scene MAE. GCS 15 Paralyzed/Sedated/Intubated d/t sob. Med Flight .\nInjuries:\nL forearm degloving injury\nL tib/fib plateau fracture\nL scapula fx\n? L clavicle fracture\nR wrist fracture\nDescending aorta dissection.\nintraparenchymal bleed\nSurgery: \nDescending aorta repair with DACRON GRAFT cross clamp time 28min\nartrial/femoral bypass\nExFix Placement I/D Left lower extremity\nI/D Vac placement Left degloving injury.\nINTRA-OP: EBL 3liters\n RECEIVED: 16Livf 32unitsPRBC, 17unitsFFP, 2cyro, 18platelets\nPMH:none\nPSH:none\nNkda\nMeds:none\n\nNEURO: Sedated with propofol and morphine. Intially unresponsive to painful stimuli. TOF . Decreased and discontinued sedation eliciting movement of all four extremities, spontaneous eye opening, and following commands late this afternoon. See serial neuro exams in Careview. Repeat head CT results pnd.\nCV:Arrived and managed per post-op CT parameters maintaining HR 80-90\nSBP 120's. Titrating Nitro/Nitpride gtts. Received several doses of labetelol ivp (see careview).\nPer Dr. weaned off vasodiliators/beta blockers.\noximetric swan placed to monitor hemodynamic status more closely.\nPAP 40/40 mean 30\nCVP 16\nC.O. 8.62\nC.I. 4.51\nHR NSR 90's\nMixed venous 80%\nRESP:Multiple vent changes made. Patient in ABG adequate with better oxygenation with current vent settings. see care view\nLungs sounds clear throughout. Suctioned for scant amt of thin clear sputum. CT to Left side. Crepitus noted with serosanginuous drainage.\nGI:Abd soft nondistened hypoactive bowel sounds. Oral gastric tube to LWS minimal output. Carafate RTC.\nRenal: Foley with yellow/clear urine output roughly 80-100cc/hr via Foley cath.\nSKIN: Left degloving injury with VAC site intact to 125mmHg. Left lower leg ex/fix with mod amt serosanginous drainage. Abrasions noted on abdomen, left hip. Left thoracotomy site with staples mod sero/sanginous drainage on occulsive dressing. +3 palpable pulses on all four extremities. Bilaterally feet with warmth/pale but pulses significantly present and patient respods to tactile stimulation.\nHEME: HCT 37 (30.1) Coags wnl.\nID: Initally hypothermic post-op. Warm with bear hugger Tmax 99.9 Levo X 48.\nEndo: Glucose intially 144 req 2 units. Currently 111 wnl\nSocial: Lives with family in . Works at . , sister, girlfriend. into visit. F/u with Social Work.\nAP:Hemodynmically stable s/p mulitrauma. Pnd CT/TLS results. Monitor all parameters.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-06-29 00:00:00.000", "description": "Report", "row_id": 1598737, "text": "T/SICU NPN 2300->0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT EASILY - FOLLOWING COMMANDS, MAE'S, PERRLA 2MM/BRISK. MSO4 Q6HR DOSE INCREASED TO 7MG W/ FAIR EFFECT - ALSO GIVEN PRN MSO4 FOR C/O BACK/CHEST/LEG PAIN. PT W/ PAIN ISSUES S/P LOGROLL - O2 SATS & VS REFLECTIVE: RESTARTED ON PROPOFOL W/(+) EFFECT - VS SLOWLY IMPROVED TOWARD PREVIOUS BASELINE. CONTINUES W/ J COLLAR AND LOGROLL PRECAUTIONS.\n\nCV: HR NSR 70-80'S, SBP 120-130'S, CVP 12-16, NO ECTOPY NOTED ON TELEMETRY. PULSES PALPABLE, SKIN PINK/WARM/DRY. PAWP 16, SYSTOLIC FILLING PRESSURES 35-40. 4A CARDIAC INDEX 4.5 - MAINTAINING GOAL TO KEEP C.I.>4.5. PERIPHERAL EDEMA NOTED. PB TO RLE FOR DVT PROPHYLAXIS. LYTES REPLETED.\n\nRESP: LUNGS CLEAR IN UPPER FIELDS, CLEAR<->DIMINISHED @R BASE - DIMINISHED @L BASE. CT CONTINUES TO 15CM SXN DRAINING ~270CC SERO/SANG FLUID OVER 8HRS. INSERTION SITE BENIGN. PT W/EPISODE OF DESATURATION @0100 - PT EXPRESSING DIFFICULTY W/BREATHING,(?)IF R/T PAIN ISSUES: O2 SAT DOWN TO 80'S, SVO2 55%(88-90%), HYPERTENSIVE/TACHYCARDIC/TACHYPNEIC. SICU HO NOTIFIED AND CXR/CTS DONE->BENIGN. PT RESUMED ON PROPOFOL W/(+)EFFECT - VS SLOWLY RETURNING TO BASELINE - ABG'S STABLE. NO CHANGE IN LUNG ASSESSMENT. SXN FOR MOD AMT BLD TINGED SECRETIONS. SEE CAREVIEW FOR VENT SETTINGS AND ABG DATA.\n\nGI: ABD SOFTLY DISTENDED W/(+)HYPOACTIVE BS, NO BM. OGT TO LWCS - SCANT BILIOUS DRAINAGE OUT - RECEIVING CARAFATE Q6HR.\n\nGU: FOLEY CATHETER PATENT DRAINING ~45CC/HR AMBER COLORED URINE.\n\nENDO: GLUCOSE LEVELS 148->131: COVERED PER SS.\n\nID: TMAX 100.6->99.0 - RECEIVING PROPHYLACTIC LEVOFLOX.\n\nSKIN: SMALL AMT SERO/SANG DRAINAGE FROM LLE - PRIMARY DSG INTACT. LUE WOUND COVERED W/VAC DSG - SCANT SERO/SANG DRAINAGE. RUE WRIST IN SPLINT. (+)PULSES AND BRISK CAP. REFILL TO AFFECTED EXTREMITIES. BACK/BUTTOCKS INTACT. THORACOTOMY INCISION WNL - STAPLES INTACT.\n\nA/P: SEDATED - RESPIRATORY STATUS STABLE S/P EVENTS OF NOC. CONTINUE PER PLAN OF CARE - MONITOR SYSTEMS/LABS FOR CHANGES - REPLETE LYTES AS NEEDED. PULMONARY HYGEINE->WEAN VENT AS TOLERATED, PAIN MGT. NEURO CHECKS AS ORDERED, GLUCOSE MONITORING. GOAL TO MAINTAIN CI >4.5. MAINTAIN C-SPINE/LOGROLL PRECAUTIONS. FULL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2107-06-29 00:00:00.000", "description": "Report", "row_id": 1598738, "text": "Event: This am attempted to decrease peep and FIO2. Patient initally tolerating though ABG PaO2 in 70's with Sat > 95%. Per Dr. propofol off to attempt to manage pain/sedation with morphine independently.\n At this point, patient desaturated to low 80's out of sync with vent, tachycardic and hypertensive. ?mucus plug, ? sedation.\nAmbued aggressively, suctioned for minimal secretions, and bolus multiple times with morphine. Resedated on propofol -> bronched by tm. for sm amt of thin blood tinged secretions. Sputum cx sent.\nDuring next hour patient noted to be saturating 90-92%. Despite increase in peep and FiO2.\nAt noon patient suddenly became tachycardic, hypertensive with elevated CVP and PA pressures. Desaturating to 70's. ICU tm present. Planned CTA to r/o PE. Followed by IVC placement.\nResults indicated lg right pleural effusion. Upon return to ICU chest tube placed, with immediate output of 700cc of serosanginuous drainage. Post chest tube ABG with remarkable improvement.\n\nNeuro: sedated on morphine opens eyes spontaneously, MAE, follows commands. Pupils equal, reactive, corneal reflexes intact.\nCV: HR sinus rhythym, tachy. MAPs 80-90. PAP 40's/20's. CVP 9-15\nC.O. 6.23 C.I. ~4. PAWP 17. Received fluid bolus for transient episodes of hypotension with response. Swan refloated following CT. During CTA swan pulled back by 5cm for study attempted to refloat following CT, patient having large amounts of ventricular ectopy. Swan pulled back to RA by surgical resident for safety and refloated back in ICU without incidence. Bilateral CT to suction with serosanginous drainage. No evidence of leak or crepitus.\nRESP: Lungs clear and diminished throughout. Currently vent settings SIMV 14/600 peep12.5 FiO2 50%. Sat>95% Chest X-ray to confirm CT and PA placement. Revealed proper placement and bilateral patchy infiltrates. Suctioned for minimal secretions.\nGI: Abd soft slightly distended hypoactive bowel sounds. CT indicated oral gastric tube to have migrated from proper placement. Advanced, placement checked and secured. Low cont suction with minimal output. Carafate. Started on TPN. And to to start tube feed via OG tube.\nRenal: Foley cath 50-100cc/hr of amber colored/clear urine.\nEndo: Glucose 130's covered with sliding scale.\nSkin: Warm, dry intact. Degloving injury with Vac intact. Ex-fix intact with minimal drainage. Abrasions on abdomen/right hip. palp pp in all extremities.\nSocial: Mother and Aunt in to visit. Social work following.\nA/P: Right chest tube placement. Cont with HD monitoring, full ventilatory support, pain control, nutrition.\n" }, { "category": "Nursing/other", "chartdate": "2107-06-29 00:00:00.000", "description": "Report", "row_id": 1598739, "text": "TSICU NPN\nO: PT W/ EPISODES OF DESAT 87%. SXNED FOR SM AMT BLDY SECRETIONS AND SEDATED W/ MS04 AND 1 BOLUS PROPOFOL W/ BRIEF IMPROVEMENT.\nREMAINS ON IMV, TV DECREASED TO 500 W/ ABG = 7.27/61/70/29/0.\nFI02 INCREASED TO 60% AND PEEP REMAINS 12.5, IMV INCREASED TO 18. REPEAT ABG 7.34/50/80/28/0. O2SAT 93-94%. CXR UNCHANGED FROM THIS AM.\nTACHY, HTN, FP STABLE W/ ADEQUATE CO/CI AND SV02 = 75%. NVS UNCHANGED. TO MAE AND FOLLOW COMMANDS. ABLE TO COMMUNICATE WELL BY NODDING.\nA: IMPAIRED PULM STATUS, INADEQUATE PAIN CONTROL.\nSTABLE NVS.\nP: TO MONITOR HEMODYNAMICS AND SUPPORT AS NEEDED. PULM TOILET.\nPAIN CONTROL, INCREASE MS04 AS NEEDED TO CONTROL PAIN. MONITOR NVS.\n\n" }, { "category": "Nursing/other", "chartdate": "2107-06-30 00:00:00.000", "description": "Report", "row_id": 1598740, "text": "T/SICU NPN 11->7A:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT/AROUSES TO VOICE, F/C'S, PURPOSEFUL MOVEMENTS, AFFECT CALM/COMPLIANT - MAE'S. PERRLA 2-3MM/BRISK. C/O PAIN [ALL OVER] WHEN ASSESSED - RECEIVING MSO4 10MG ~Q2HR W/(+)RELIEF - TOLERATING TURNS WELL/BETTER. CONTINUES W/CERVICAL COLLAR - TLS CLEARED, LOGROLL PRECAUTIONS D/C'D.\n\nCV: HR NSR 90'S<->100, SBP 130'S, CVP 10-12, PAP 30-40'S/20, PAWP 19 CI 4.2. SKIN PALE PINK/WARM DRY. PERIHERAL EDEMA UNCHANGED - PULSES PALPABLE - CAP REFILL <3 SEC. IVF TO KVO - TPN @73CC/HR. K+ MG+ CA+ REPLETED. HCT 30.7(32.5), INR 1.3(1.4).\n\nRESP: LUNG SOUNDS CLEAR IN UPPER FIELDS - DIMINISHED @B/L BASES. CT'S TO L POSTERIOR AND R ANTERIOR WNL DRAINING SERO/SANG FLUID - NO AIR LEAK NOTED ->SLIGHT DRAINAGE NOTED FROM L CT SITE, R CT SITE BENIGN. VENTED ON SIMV 500X18, 60% PEEP 12.5 - OXYGENATION IMPROVED DURING SHIFT: SAT O2 93->97%, SVO2 73->80%, OVERBREATHES VENT W/POSITION CHANGES: SEE CAREVIEW FOR ABG DATA.\n\nGI: ABD SOFTLY DISTENDED W/(+)HYPOACTIVE BS, NO BM. RECEIVING CARAFATE Q6HR - TROPHIC TF'S INITIATED @6AM: IMPACT W/FIBER @10CC/HR - RESIDUALS TO BE CHECKED Q4HR - CHECK W/SICU HO BEFORE ADVANCING RATE. ALSO RECEIVING TPN.\n\nGU: FOLEY CATHETER PATENT DRAINING CLEAR/AMBER COLORED URINE >30CC - U/O TRENDING DOWN S/P CHANGE IN IVF GGTS - SICU HO AWARE, MONITORING.\n\nENDO: GLUCOSE LEVELS <160 - COVERED W/SSRI AS ORDERED.\n\nID: TMAX 100.4->100.0 - LEVOFLOX COURSE COMPLETED. NO FURTHER ABX ORDERED AT THIS TIME. WBC 7.5(8.0).\n\nSKIN: LLE W/ ACE WRAP & EX FIX APPLIANCE DRAINING SM AMTS SERO/SANG FLUID, LUE W/SCANT DRAINAGE NOTED - CONTINUES ON WOUND VAC->PRIMARY DSG INTACT. THORACOTOMY INC UNCHANGED - STAPLES SECURELY INPLACE, SCANT DRAINAGE NOTED. R WRIST IN SPLINT W/ BRUISING UNCHANGED. SEVERAL ABRASIONS THROUGHT SLOWLY HEALING - D/I. BACK/BUTTOCKS INTACT.\n\nA/P: HEMODYNAMICALLY STABLE - IMPAIRED RESP STATUS->IMPROVED - PAIN ISSUES BETTER CONTROLLED. CONTINUE PER PLAN OF CARE: MONITOR SYSTEMS/LABS FOR CHANGES, REPLETE LYTES AS NEEDED, AGGRESSIVE PULMONARY HYGEINE. ASSESS FOR ADEQUATE PAIN CONTROLL AND MEDICATE AS ORDERED. ASSESS FOR TOLERANCE OF TROPHIC TF'S - CHECK W/SICU HO BEFORE ADVANCING TOWARD GOAL RATE. NEURO EXAMS AS ORDERED. MONITOR U/O. TPN AS ORDERED. GLUCOSE MONITORING. FULL SUPPORT/COMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-04 00:00:00.000", "description": "Report", "row_id": 1598753, "text": "Resp care Note:\n\nPt intub on mech vent as per Carevue. Lung sounds coarse suct for mod th bldy sput. Attempted to decrease PSV however pt decompensated and returned to previous setting. PSV wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-04 00:00:00.000", "description": "Report", "row_id": 1598754, "text": "TRAUMA SICU NPN\nO: STABLE OVERNOC. REMAINS NST W/ FREQUENT APC'S. BP STABLE. HTN W/ ACTIVITY. 10PSV OVERNOC W/ STABLE 02SATS AND ABG. DENIED SOB. SXN FOR LGE AMT THICK BLOODY SECRETIONS. DECREASED TO 5PSV ABT 4AM AND W/IN 30MIN, C/O OF SOB, SRR 30-35 WITH LOW TV. ?ED WHETHER IT WAS ACTIVITY RELATED. AMBUED AND ALLOWED TO REST X1/2HR WITH NO IMPROVEMENT. ATTEMPTED 10MG MS04 TOTAL W/ NO CHANGE IN RESP STATUS. PLACED BACK ON\nPSV 10 WITH IMPROVEMENT. RR 15-18 WITH TV 750-800. 02SAT 99%. NO MORE C/O SOB.\nA: FAILED ATTEMPT TO WEAN THIS AM, ?PAIN/ACTIVITY RELATED VS PULMONARY INJURY/SECRETIONS.\nP: PT IS TO HAVE EPIDURAL PLACED TODAY FOR THORACOTOMY AND SCAPULA FX PAIN. ATTEMPT TO WEAN ONCE EPIDURAL IN PLACE AND PAIN IS CONTROLLED. ?BRONCH PRIOR TO EXTUBATION. TO MONITOR.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-04 00:00:00.000", "description": "Report", "row_id": 1598755, "text": "NPN (0700-1530) Review of Systems:\n\nNeuro: Pt alert and appropriate, mouthing words and nodding head appropriately. PERRL. MAE on bed. IV MSO4 Q2hrs for pain.\n\nCV: ST c hr=100-110. SBP=130-160 with episodes up to 180s with stimulation and movement. Color pink, skin warm and dry, palpable pulses and dopplerabel pt pulses. Venodyne on RLe in place.\n\nResp: LS dm at bases. PSV of 10, peep decreased to 5 and Fio2 increased to 50% and pt tol well c good ABGs for settings. Pt suctioned for thick blood tinged plugs/secretions, requires frequent pulm toilet. R&L CT intact, sm air leak on L noted and L continue to drain mod amt of ss drainage. L>R.\n\nGI: Abd soft, Hypoactiva BS. Impact with fiber resatrted at 30cc/hr and plan to advance to goal of 70cc/hr. No BM. Reglan and carafate continue.\n\nGU; Indwelling foley intact and draining clear yellow urine. Calcium and potassium repleted.\n\nHeme: HCt slowly decreasing, Team aware. Plan to recheck HCT this eve.\nlovenox restarted per Team.\n\nID: Temp=99.9po this shift. IV zosyn started. Last pan Cx .\n\nEndo: RISS\n\nSkin: Skin warm and dry. Abrasions healing over and all D&I. L leg incision intact and drainig sm amt ss drainage, dsd intact. Pt turned and repositioned and skin care provided.\n\nSOC; Mother in and questions answered.\n\nA/P: Continue full support as above. Continue with pulm toilet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-07-04 00:00:00.000", "description": "Report", "row_id": 1598756, "text": "SOCIAL WORK NOTE:\nSpoke with pt and his mother today to offer support. Pt was alert and intubated and was gesturing appropriately with his hands and eyes and mouth. He seems appropriately frustrated by experience of intubation but was not agitated. mother seems in good spirits. This SW remains available. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2107-07-04 00:00:00.000", "description": "Report", "row_id": 1598757, "text": "Resp. Care Note\nPt remains intubated and vented as per settings on resp. flowsheet. Pt transported to and from fluor today for evaluation of L diaphragm. Pt ambued during procedure to allow for timing of spont breaths. Tolerated transport well. vent support, wean PSV in AM as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2107-07-05 00:00:00.000", "description": "Report", "row_id": 1598761, "text": "S/O\nNeuro: C/O pain = 9, given MSO4 5 mg IVP x4 without change in CT pain, did relieve musculoskeletal pain. Epidural placed by anesyhesia, lidcaine bolus given with several hours of pain relief and quiet rest. Started on Dilaudid 20mcg/mL and Bupivicaine0.1% epidural drip, given 5 mL bolus x 2 with pain decrease transiently from 9 ->4, and gtt titrated up from 6 ->8 mL/hr. Pain recurred, rebolused with 5 mL and gtt increased to 9 mL. Spoke with MD who agrees to increase Bupivicaine concentration if continues with intolerable pain due to chest tubes and scapula fracture.\n\nAlert alternated with lethargic related to activities and care. No neuro deficits.\n\nCV: Tachycardic and hypertensive within baseline limits. Intermittent, brief epsiodes of HR increased to 160's with coughing. Very rare PVCs noted x 2.\n\nRESP: Weaned to extubate. Currentlu on face mask 100% with ABG showing pt to tolerate current care. Coughing up large amounts of thick sputum with old and bright red blood in episode. Right CT without leak, draining scant amts of serosang drainage. Left doubled CT with small air leak, draining large anounts of serosanguinous/straw drainage. LS as noted in flowsheet.\n\nGI: Abdomen tender due to \"gas\" rather than pain. TF held due to extubation. Discussed beginning bowel regime with surgical team -> they will do rectal, then order approprite treatment. OGT d/c'd with ETT.\n\nGU: Foley draining qs u/o.\n\nSKIN: Abrasions, bruisies over body healing. Left thigh sutures intact, craining serous drainage. Left thoracotomy clean, dry. well-approx. Left forearm injury d/c'd from VAC and changed to xeroform/DSD.\n\nMUSCULOSKELETAL: Pt in too much pain today to tol CPM -> will try again tomorrow with epidural now in effect. Continues with scapula pain -> surgical eam and ain mngmnt team to evaluate for maximum relief without respiratory risks.\n\nPSYCHOSOC: Mom in ths afternoon. I will call before leaving to notify her of extubation.\n\nA/P: Continue pulmonary toilet. Moniter, treat respiratory symptoms. Moniter HR and BP -> discuss again with MDs as appropriate re: anti-hypertensive treatment eother with pain mngmnt or BP tx as appropriate to cause. Follow up with haemolytic eval and decreasing Hct. Follow up with effective pain mngmnt plan. Follow up with bowel plan and nutrition re: po's. Follow up with positive cx'x therapy and status.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-05 00:00:00.000", "description": "Report", "row_id": 1598762, "text": "Addendum: Preceding note written by 0700-1900 shift RN ->awaiting careview key\n" }, { "category": "Nursing/other", "chartdate": "2107-07-06 00:00:00.000", "description": "Report", "row_id": 1598763, "text": "T/SICU NPN 1900-2300:\n\nNEURO: PT ALERT/ORIENTED/APPROPRIATE/COMPLIANT W/CARE. MAE'S. C/O PAIN TO BACK, SHOULDRES/RIBS. EPIDURAL INFUSING @9CC/HR - SENSORY LEVEL T4: EPIDURAL INSERTION SITE WNL. GIVEN PRN MSO4 FOR MUSCULOSKELETAL PAIN W/(+)EFFECT. RESTING COMFORTABLY - SLEPT ON/OFF. CERVICAL COLLAR ON UNTIL PAIN ISSUES BETTER CONTROLLED TO PROPERLY ASSESS C-SPINE FOR CLEARANCE.\n\nCV: HR ST 100-110'S, SBP 140'S. NO ECTOPY NOTED ON TELEMETRY. SKIN PALE, ICTERIC. PULSES PALPABLE. TRANSFUSED 1U PRBC'S ON EVE'S. LYTES REPELETD.\n\nRESP: PT STABLE S/P EXTUBATION - SATS 95-99%. RR 14-20. DENIES SOB/DOE. LUNG SOUNDS CLEAR IN UPPER FIELDS, DIMINISHED @B/L BASES. STRONG PRODUCTIVE COUGH - ABLE TO RAISE SECRETIONS FOR ORAL SXN - THICK/BLD TINGED. O2 COOL NEB VIA FACE TENT @50%. CT'S TO SXN W/ SCANT DRAINAGE NOTED - SM LEAK CONTINUES ON L SIDE - SEE CAREVIEW FOR FURTHER DETAIL.\n\nGI: ABD SOFT W/(+)BS, NO BM. DENIES N/V. TPN INFUSING AS ORDERED. OGT D/C'D.\n\nGU: FOLEY CATHETER PATENT DRAINING ADEQUATE VOLUME OF CLEAR/ TINGED URINE.\n\nID: TMAX 100.6\n\nENDO: GLUCOSE <130 - NO SSRI COVERAGE THIS SHIFT.\n\nSKIN: NO NEW SKIN ISSUES - BACK/BUTTOCKS INTACT - SEE CAREVIEW FOR DETAILED ASSESSMENT.\n\nA/P: STABLE S/P EXTUBATION. PAIN CONTROL ISSUES CONTINUE. CONTINUE PER PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-06 00:00:00.000", "description": "Report", "row_id": 1598764, "text": "TRAUMA SICU NPN\nO:\nNEURO: ALERT, OX3. APPROPRIATE AND COOPERATIVE, MAE AND FOLLOWS COMMANDS. C-COLLAR REMAINS ON. ABLE TO ASSIST W/ MOVING. MODERATE RELIEF FROM EPIDURAL. RECEIVING ABT 10MG MS04 Q4HRS W/ RELIEF.\n\nCV: STABLE, REMAINS TACHY 1088-120'S NST. BP STABLE.\n\nRESP: REMAINS ON 50% FACE TENT W/ STABLE 02SATS AND STABLE ABG. STRONG PRODUCTIVE COUGH FOR THICK BLOODY SECRETIONS. C/O DIFFICULTY EXPANDING CHEST, ESP AFTER ACTIVITY. RECOVERS W/ PAIN MED AND PRODUCTION OF SPUTUM. SRR 20'S.\n\nRENAL: BRISK U/O VIA FOLEY.\n\nGI: PT RECEIVING TPN FOR NUTRITION SUPPORT. ABD SOFT, NON-TENDER.\nNO BM.\n\nENDO: BS 130'S AND RECEIVING SS INSULIN.\n\nHEME: HCT STABLE AT 27.9. LFTS ELEVATED ? CHOLELEHIASIS VS HEMOLYSIS.\n\nID: TMAX 100.6. ON ABX.\n\nSKIN: NO CHANGE, WOUNDS AND INCISIONS HEALING.\n\nA: STABLE POST EXTUBATION.\n\nP: READY TO INCREASE ACTIVITY. 00B TO CHAIR. TO MONITOR. PULM TOILET AND PAIN MANAGEMENT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-07-06 00:00:00.000", "description": "Report", "row_id": 1598765, "text": "SOCIAL WORK NOTE:\n mother has questions about possibility of free care for pt due to limitations of his insurance plan. I will refer to covering RNCM for assistance with these issues. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2107-07-06 00:00:00.000", "description": "Report", "row_id": 1598766, "text": "NPN UPDATE\n: Patient hemodynamically stable. Down to x-ray for flexion and extension films. See careview for vital signs and I&O's.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 1598773, "text": "TRAUMA/SICU NPN\nO:\nNEURO: AWAKE, ORIENTED X3, MAE AND FOLLOWS COMMANDS. USING PCA FOR PAIN CONTROL W/ GD EFFECT.\n\nCV: STABLE. REMAINS TACHY 100-120 NST W/ OCC PVC'S AND COUPLETS. PERICARDIAL DRAIN FLUSHES EASILY AND ASPIRATES EASILY BUT W/ NO NEW DNGE. ECHO FROM TODAY SHOWS REACCUMULATION. PT IS SCHEDULED FOR\nPERICARDIAL WINDOW IN AM.\n\nRESP: LS COARSE W/ STRONG PRODUCTIVE COUGH OF THICK YELLOW SPUTUM. 02SATS DOWN TO 88% WHEN ASLEEP. IMPROVES W/ CDB. FACE TENT UP TO 70% AND 4LNP ADDED W/ IMPROVEMENT.\n\nRENAL: VOIDED ABT 800CC AMBER U/O.\n\nGI: SENT FOR SWALLOW STUDIES TODAY WHICH SHOWED DELAYED SWALLOWING W/ LIQUIDS. ASPIRATION PRECAUTIONS AND THICKENER FOR ALL LIQUIDS. TPN STARTED. NPO AFTER MN FOR PROCEDURE TOMORROW. ABD SOFT, BS PRESENT.\n\nHEME: STABLE. T & S SENT IN PREP FOR OR.\n\nID: AFEBRILE, ABX.\n\nSKIN: BACKSIDE INTACT. THORACOTOMY INCISION W/ STAPLES, C&D. OLD CT SITE COVERED W/ DSD. LLE W/ STERISTRIPS AND SOME STAPLES. NO DNGE. LLE IN CPM MACHINE.\n\nA: HEMODYNAMICALLY STABLE W/ PERICARDIAL EFFUSION. IMPAIRED PULM STATUS. PAIN ADEQUATELY CONTROLLED.\n\nP: TO MONITOR FOR S/S TAMPONADE OVERNOC. PAIN CONTROL W/ PCA\n PULM TOILET. C&DB. TPN AND NPO FOR PERICARDIAL WINDOW IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-14 00:00:00.000", "description": "Report", "row_id": 1598774, "text": "T/SICU NPN 11P->7A:\n\nNEURO: PT ALERT/ORIENTED/AFFECT AND QUESTIONS APPROPRIATE. SPEECH SOFT/CLEAR. MAE'S - PERRLA 3MM/BRISK. COMPLIANT W/CARE. STRONG COUGH EFFFORT. PAIN WELL CONTROLLED W/MSO4 PCA.\n\nCV: HR ST 100-110'S W/ /OCCASIONAL ECTOPY NOTED ON TELEMETRY. BP'S 105-130'S/50-60'S. CVP 5-8. C/O CP R/T INJURIES - DENIES PAIN RADITING TO JAW/EXTREMITIES. PERICARDIAL DRAIN PATENT DRAINING SMALL AMT SERO/SANG FLUID - FLUSHED Q4HR AS ORDERED. SKIN PALE/WARM/DRY. PULSES EASILY PALPABLE. K+ AND MG+ REPLETED.\n\nRESP: LUNG SOUNDS CLEAR<->COARSE IN UPPER FIELDS, COARSE<->DIMINISHED @BASES. STRONG PRODUCTIVE COUGH - ABLE TO RAISE SECRETIONS AND CLEAR W/ORAL SXN INDEPENDENTLY. SPUTUM THICK/TAN. O2 VIA FACE TENT 40% WHILE AWAKE, UP TO 70%WHEN SLEEPING TO MAINTAIN SATS >97%. 22 16-22.\n\nGI: ABD SOFT, NT/ND W/(+)BS - NO BM. DENIES N/V. NPO AFTER MN FOR SURGERY IN AM - TPN STARTED.\n\nGU: VOIDING SPONTANEOUSLY W/O DIFFICULTY - ADEQUATE VOLUMES OF CLEAR/AMBER COLORED URINE.\n\nENDO: STABLE\n\nID: TMAX 98.2 - CONTINUES ON CEFAZOLIN.\n\nSKIN: COCCYX NOTED TO BE PINK/BLANCHABLE - EARLY STAGE I PRESSURE ULCER. PT ENCOURAGED TO REMAIN ON SIDES VS BACK TO MAINTAIN SKIN - PT STATES DIFFICULTY REMAINING ON SIDES R/T RIB/SKELETAL PAIN - ENCOURAGE TO USE PCA TO COMPENSATE. SKIN ASSSESSMENT OTHERWISE UNCHANGED.\n\nA/P: STABLE - PAIN WELL CONTROLLED. TO O.R. IN AM FOR PERICAREDIAL WINDOW. (?) TXFER TO FLOOR S/P SURGERY IF PT REMAINS STABLE.\n" }, { "category": "Echo", "chartdate": "2107-07-12 00:00:00.000", "description": "Report", "row_id": 73073, "text": "PATIENT/TEST INFORMATION:\nIndication: S/P aortic repair.\n? Pericardial effusion.\nStatus: Inpatient\nDate/Time: at 20:28\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nA catheter is noted in the pulmonary artery.\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is a large pericardial effusion. There is left atrial\ncollapse. There is right ventricular diastolic collapse, consistent with\nimpaired fillling/tamponade physiology.\n\nGENERAL COMMENTS: The patient is tachycardic (HR>100bpm). Emergency study\nperformed by the cardiology fellow on call.\n\nConclusions:\nVentricular function cannot be adequately assessed. There is a very large\npericardial effusion which is somewhat loculated (largest accumulation around\nthe right atrium and right ventricle and around the left atrium with relative\nsparing of the apex). There is fibrin stranding. There is marked RV diastolic\ncollapse and left atrial/left ventricular compression, c/w pericardial\ntamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2107-07-22 00:00:00.000", "description": "Report", "row_id": 72922, "text": "PATIENT/TEST INFORMATION:\nIndication: R/O Pericardial effusion.\nHeight: (in) 74\nWeight (lb): 130\nBSA (m2): 1.81 m2\nBP (mm Hg): 140/70\nStatus: Inpatient\nDate/Time: at 15:14\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nborderline normal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. The left\nventricular inflow pattern is normal for age.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade. There is no significant respiratory\nvariation in mitral/tricuspid valve flows.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is low normal (LVEF 50%). Right ventricular\nchamber size is normal. Right ventricular systolic function is borderline\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. The mitral valve leaflets are structurally normal. There is\na trivial/physiologic pericardial effusion. There are no echocardiographic\nsigns of tamponade.\n\nCompared to the previous study of , left and right ventricular\ncontractile function appears slightly reduced; otherwise no major change.\n\n\n" }, { "category": "Echo", "chartdate": "2107-07-15 00:00:00.000", "description": "Report", "row_id": 72923, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p pericardial window. Evaluate for pericardial effusion\nHeight: (in) 74\nWeight (lb): 135\nBSA (m2): 1.84 m2\nBP (mm Hg): 152/69\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 15:48\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is moderately dilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A left pleural effusion is present.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). A diastolic septal \"bounce\" is\npresent. Right ventricular chamber size and free wall motion are normal. The\naortic root is moderately dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. Trace aortic regurgitation is\nseen. The mitral valve leaflets are structurally normal. There is no\npericardial effusion. Alarge left sided pleural effusion/clot is seen in the\npleural space. There is a region of increased echogenicity in the aortic\narch/descending aorta consistent with the site of the aortic repair.\n\nBy report, no change from the previous study ().\n\n\n" }, { "category": "Echo", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 72924, "text": "PATIENT/TEST INFORMATION:\nIndication: ? Pericardial effusion.\nHeight: (in) 74\nWeight (lb): 135\nBSA (m2): 1.84 m2\nBP (mm Hg): 124/59\nStatus: Inpatient\nDate/Time: at 14:08\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPleural effusion is present.\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. Physiologic mitral regurgitation is seen (within normal\nlimits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Moderate [2+]\ntricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. There is no\npulmonic valve stenosis.\n\nPERICARDIUM: There is a large pericardial effusion. The effusion appears\nloculated. Echocardiographic signs of tamponade may be absent in the presence\nof elevated right sided pressures.\n\nGENERAL COMMENTS: The patient is tachycardic (HR>100bpm). The\nechocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic leaflets (3) appear\nstructurally normal with good leaflet excursion. Mild (1+) aortic\nregurgitation is seen. The mitral leaflets are structurally normal. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary hypertension.\nThere is a large pericardial effusion which is loculated primarily anteriorly.\nThe visceral pericardium is focally thickened at the AV groove anteriorly.\nFibrin stranding is evident. There is a septal \"bounce\" suggesting some\npericardial constriction. There are no echo-Doppler findings to suggest\ntamponade (does not exclude).\nThere is increased echogenicity in the aortic arch/descending thoracic aorta\n(? sight of aortic repair).\nCompared with the prior study of (views not entirely comparable),\nthere has been significant reaccumulation of pericardial effusion, especially\nanteriorly.\n\nSerial evaluation is recommended.\n\n\n" }, { "category": "Echo", "chartdate": "2107-07-12 00:00:00.000", "description": "Report", "row_id": 73037, "text": "PATIENT/TEST INFORMATION:\nIndication: S/P pericardiocentesis.\nStatus: Inpatient\nDate/Time: at 22:38\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion. The number of aortic valve leaflets cannot be determined.\nMild (1+) aortic regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nViews are limited (no subcostal view obtained).\nThere is a small circumferential echo-dense pericardial effusion.\nCompared with the prior study of , most of the pericardial fluid has\nbeen removed and compression of the right ventricle is no longer present.\n\n\n" }, { "category": "ECG", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 176248, "text": "Probable ectopic atrial rhythm\nNonspecific lateral ST-T abnormalities - clinical correlation is suggested\nSince previous tracing on same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2107-07-13 00:00:00.000", "description": "Report", "row_id": 176249, "text": "Probable ectopic atrial tachycardia\nLateral T wave changes are nonspecific\nSince previous tracing of , change in P wave morphology\n\n" }, { "category": "ECG", "chartdate": "2107-07-02 00:00:00.000", "description": "Report", "row_id": 176250, "text": "Sinus tachycardia with a single atrial premature beat. RSR' pattern in lead V2.\nVoltage is probably normal for age. No previous tracing available for\ncomparison.\n\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2102-12-21 00:00:00.000", "description": "Report", "row_id": 100447, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 60\nWeight (lb): 173\nBSA (m2): 1.76 m2\nBP (mm Hg): 118/60\nStatus: Inpatient\nDate/Time: at 15:06\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis moderately depressed. There is no resting left ventricular outflow tract\nobstruction. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. There are focal calcifications in the ascending aorta.\nThere are focal calcifications in the aortic arch. There are focal\ncalcifications in the descending thoracic aorta.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is a\nminimally increased gradient consistent with minimal aortic valve stenosis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. The main\npulmonary artery and its branches are normal. No color Doppler evidence for a\npatent ductus arteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is moderately depressed (ejection fraction 30-40 percent) secondary\nto severe hypokinesis of the interventricular septum and at least mild\nhypokinesis of the rest of the left ventricle. No masses or thrombi are seen\nin the left ventricle. Right ventricular chamber size and free wall motion are\nnormal. There are focal calcifications in the aortic arch. The aortic valve\nleaflets are moderately thickened. There is a minimally increased gradient\nconsistent with minimal aortic valve stenosis. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. The left ventricular\ninflow pattern suggests impaired relaxation. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2102-12-17 00:00:00.000", "description": "Report", "row_id": 276262, "text": "Atrial sensed ventricular paced\nPacemaker rhythm - no further analysis\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2102-12-14 00:00:00.000", "description": "Report", "row_id": 276263, "text": "Atrial sensed - ventricular paced rhythm. Since the previous tracing\nof ventricular ectopy is not seen and the rate is faster.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2102-12-13 00:00:00.000", "description": "Report", "row_id": 276264, "text": "Atrial sensed ventricular paced rhythm with a ventricular premature beat which\nis followed by A-V pacing. Since the previous tracing of ventricular\nectopy is seen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2102-12-06 00:00:00.000", "description": "Report", "row_id": 276265, "text": "Ventricular pacing.\nPacemaker rhythm - no further analysis\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2102-12-06 00:00:00.000", "description": "Report", "row_id": 276266, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2102-12-06 00:00:00.000", "description": "Report", "row_id": 276267, "text": "Atrial sensed-ventricular paced mechanism, rate 81. Compared to the previous\ntracing of no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-12-07 00:00:00.000", "description": "Report", "row_id": 1411389, "text": "T/SICU NPN: 1500-1900\nS: \"IT'S HARD TO BREATH.\"\nO: C/O SOB RR TEENS TO 20'S SAO2 > 96% on 40% FT\nABG: 105-37-7.30-19-7 LUNGS CLEAR, DECREASED AT BASES HR/BP STABLE\nCVP 8-15 PAD 21-28 SICU MD--DR. NOTIFIED CXR ORDERED AND DONE\n.5MG IV MSO4 X 2 U/O 8-50CC/HR D5NS AT 80CC/HR\nA/P: CONTINUE METABOLIC ACIDOSIS FOLLOW LAB VALUES FOLLOW PULMONARY/HEMODYANMICS STATUS\n\n" }, { "category": "Nursing/other", "chartdate": "2102-12-08 00:00:00.000", "description": "Report", "row_id": 1411390, "text": "T/SICU Nursing Progress Note\nS: \"I am having difficulty breathing\"\nO: Neuro: alert, oriented. Somewhat anxious at times but responds well to reassurance from nurse. Denies pain except when turning but refuses pain meds at present.\nCVS: stable, see carevue for hemodynamics. V paced without ectopics\nRESP: on 40 % cool neb with continued metabolic acidosis. Early in morning pt was audibly wheezing and complaining of difficulty breathing. Received albuterol rx with some relief. Weak congested cough.\nRENAL: resolving atn, cr now 1.2, ca++ being repleted, urine output initially low, now 60/hr. Had some leaking around foley, more fluid instilled in balloon. Continues to have edema in face and extremitites\nGI: ng to drainage, draining bilious liquid. Belly soft with no bowel sounds. JP with minimal drainage.\nID: afebrile, wbc 11, on fluconozole, flagyl and ampicillin.\nENDO; on ssri, no supplementation needed\nHEME: hct stable\nskin: midline incision with small amount of staining at upper pole.\nA: stable but continued unresolved metabolic acidosis, fluid overload\nresolving atn\nP: continue to monitor closely ?? take out swan, start mobilizing out of bed today\n" }, { "category": "Nursing/other", "chartdate": "2102-12-09 00:00:00.000", "description": "Report", "row_id": 1411392, "text": "RN progress note\nneuro: AAO x 3; calm, coop, though reluctant to move, CDB. No focal deficits.\n\nCV: V-paced; native rhythm junctional, WAP; no VEA. BPS 100-140's\n\nPulm: rhonchorous throughout, clears with CDB, thick white sputum. Dim bases. Face tent all noc until bath, OOB, then NP 4L with sats>94%\n\nGI: abd softly distended; silent. No nausea. NGT bilious, 50cc/12h.\n\nGU: UOP 30-50cc/hr. RF wnl.\n\nMS/derm: abd dsg D/I, sm amt old drng. JP scant s/s. Remains anasrcic; wt down 2.6kg. Skin intact. PCA MS w/ adequate analgesia.\n\nID: cont low grade fever; Tmax 99.8po. WBC up to 12.2 from 11. H.pylori +, tx pending.\n\nP: cont to enc CDB, OOB. Dsg change by team. ?transfer.\n" }, { "category": "Nursing/other", "chartdate": "2102-12-08 00:00:00.000", "description": "Report", "row_id": 1411391, "text": "NPN (0700-) REview of Systems:\n\nNeuro: Pt 2-3, occasionally confused to place. Pt pleasant most of the shift, but had episode of anxiety, pt was irritable and angry towards hospital staff, reoriented with little effect. IV MSO4 PCA started with good effect, pt using appropriately.\n\nCV: Vpaced hr=80s, SBP=130-140s and up to 170s this am, IV lopressor started with good effect. Pa lince d/c'd and TLC changed over a wire. Venodynes in place.\n\nREsp: LS course and dm. Pt with expiratory wheezing and congestion, required nebs tx x2 with fair effect and 10mg IV lasix with good diuresis. +Weak NPC. SaO2=95-98% 40% Fios face tent.\n\nGI: Abd obese and distended, tender to touch, absent BS. NPO, NGT to LWS dna draining bilious drainage. IV protonix continues. No BM. LUQ JP drain to bulb suction, draining serous drainage.\n\nGU: Indwelling foley intact and draining clear yellow urine.\n\nHeme: Am HCT=32.8. Heparin SQ .\n\nID: Afebrile. IV flagyl, fluconazole, ampicillin and lovofloxacin continue.\n\nEndo: No coverage per RISS.\n\nSkin: Abdominal incision changed by team this am, D&I. Skin care provided.\n\nAcitivity: OOB to chair with slide board and pt tolerated well.\n\nPlan: Continue support. Encourage cough and deep breathing. transfer to floor when stable.\n" }, { "category": "Nursing/other", "chartdate": "2102-12-06 00:00:00.000", "description": "Report", "row_id": 1411385, "text": "TSICU ADM NOTE\nPt is an 81 yo female resident of who came to EW with c/o abd pain X3 days, coffee ground emesis and BRBPR. Abd Xray in EW showed increased free air in abd. Pt in ARF on adm, with BUN 41/Creat 3.3. To OR for exp lap, resulted in patch of duodenal perf and resection of left liver mass with JP placement.\n\nROS:\n\nNEURO: Primarily speaking. Sedated on 10mcg/kg/min of propofol on admission. Opens eyes with stimulation. Able to follow commands with help of speaking MD. . 2mg MSO4 for pain. Propofol off after 2hrs. Pt awake off/on and mouthing simple words.\n\nRESP: ABG on adm reflect metabolic acidosis (see carevue for all values). O2 sat 90-93%. LS clear/dim at bases, minimal secretions with suction. Vent settings changed to SIMV 600X14 60%O2 5PEEP/5PS. ABG cont to reflect metabolic acidosis, but slowly improving. Will follow.\n\nCV: Pt DDD paced, rate 70s with rare PVC's. BP 100-130s/40s-60s. PAP's 40s/10s, CVP 11. CO , CCI . Swan difficult to wedge, however wedge value does correlate with CVP/diastolic PAP. Cardiology in to review pacer; preliminary report states pacer battery/sensitivity/capture intact.\n\nHEME: Hct 36.4. pboots for DVT prophylaxis.\n\nGI: Abd lg, obese. BS absent. NGT to LCS with small amt thick brown output. Protonix for GI prophylaxis.\n\nGU: BUN 37, Creat 2.2. Initial u/o adequate, then began to trend down. Total 1000cc NS bolus with fair effect. LR cont at 100/hr. Lytes WNL.\n\nID: Temp 95.5 on adm, warmed with bair hugger. WBC WNL. Per surgical team, abd had increased amt of purulent drainage during .\n\nENDO: NIDDM, FS WNL no need for coverage.\n\nSOCIAL: Pt lives at . Daughter, is HCP. Pt was DNR at but has been lifted for current . Daughter phoned and is aware of pt's status.\n\nASMT: 81 yo s/p exp lap with metabolic acidosis and likely to require lg fluid resusciation.\n\nPLAN: Cont to monitor VS, I+O, hemodynamics. Replete fluid/lytes, monitor renal status, monitor labs and plan to remain intubated until acidosis corrected.\n" }, { "category": "Nursing/other", "chartdate": "2102-12-06 00:00:00.000", "description": "Report", "row_id": 1411386, "text": "resp. care\npatient placed on vent after o.r. tidal vol and resp. rate increased after initial abg. acute renal failure. no pulm hx. bbs clear. continue current care. see rt flowsheet for more.\n" }, { "category": "Nursing/other", "chartdate": "2102-12-07 00:00:00.000", "description": "Report", "row_id": 1411387, "text": "T-SICU NSG PROGRESS NOTE\nS/O:\n\n NEURO:Pt opens eyes spontaneously, and MAE's to command. PERL. MSO4 boluses for pain. Pt has periods of anxiety, but calms w/ reassurance.\n\n CV:HR:80's ,V paced, no ectopy. Ca repleted x 1, other lytes wnl. Periods of hypotension responded to NS boluses x 3. PA's:40's/20's, CVP:, C.O./C.I.:5.4/3.1. BP:90-120/50-60.\n\nRESP:Intubated and vented: IMV 600 x 14x 50%,5&5. Lungs clear but diminished at bases. Sxnd for scant to none secretions. Acidosis resolved. ? plans to wean/extubate today.\n\nGI: Abd firmly distended.NPO w/ LR at 100cc/hr. NGT to LCWS for small amts of brown drng. Protonix as ordered. Midline dsg w/ small amt of serosang drng, but intact.\n\nGU: BUN/CR normalizing. UO:25-60CC/HR.\n\nHEM/ID: Hct:33.6, repeat pending. WBC wnl. Tmax 37.4.\n\nENDO: Blood glucose:88-127. No coverage required per s.s.\n\nSKIN: Midline incision as described. Backside intact.\n\nACTIVITY: Bedrest.\n\nSOCIAL: Visited by Neice last evening. No calls overnight.\n\nA:Hemodynamically stable s/p fluid boluses.\n\nP:Cont. to monitor hemodynamics. Support w/ IVF as needed.Cont abx's.\n" }, { "category": "Nursing/other", "chartdate": "2102-12-07 00:00:00.000", "description": "Report", "row_id": 1411388, "text": "NPN 0700-1500\nO; I LIKE YOGURT WHEN CA I HAVE SOME TO EAT.\n\nNEURO ;VERY PLEASANT AND COOPERATIVE LADY WHO REMAINS NEUROLOGICALLY INTACT. FOLLOWS SIMPLE COMMANDS ASKING APPROPRIATE QUESTIONS.\n\nRESP; EXTUBATED AROUND 9AM INITIALLY SATS 91-93 % ON TENT MASK CHANGED TO 70% FACE MASK AND WEANED TO 40% FACEMASK. LUNG SOUNDS CLEAR UPPER ? CRACKLES AT BASES BUT PT TALKING THROUGH EXAM.RR 17-20 SATS 97 % CURRENTLY ENCOURACED TO DEEP BREATH EVERY HOUR. WEAK UNPRODUCTIVE COUGH.\n\nCVS.T 37.7 CORE,HEMODYNAMICALLY STABLE WITH CI 7.8 BP 116-125/58 100% V PACED(INTERNAL DDD) CVP RUNNING PAD 19-28. WITH REP VARIANCE.\n\nGU; PASSING 30-40 MLS AMBER URINE ? SOME LEAK AROUND CATHETAR WHEN C/O OF SPASM.\n\nGI; NPO MIN AMOUNT BILIOUS DRAINAGE VIA NGT. NPO HAD SOME ICE CHIPS.\nBELLY FIRM BUT NOT DISTENTENDED . HYPO ACTIVE BS. NO STOOL NO FLATUS.\n\nENDO NO COVERAGE ON RIIS.\n\nHEME ;STABLE.,\n\nID; ANTIBIOTICS CHANGED FOR IMPROVING RENAL FUNCTION.\n\nWOUND STABLE MIN SEROUS DRAINAGE,ON DSD, SMALL AMOUNT SERO/SANQ VIA J/P.. SKIN PINK. WARM AND DRY.\n\nFAMILY ; NEICE INTO VISIT DAUGHTER IN CONTACT BY PHONE, AS HAS BAD COLD. AND UPDATED WITH PT CURRENT CONDITION.\n\nA/P IMPROVING SLOWLY. CONTINUE WITH PRESENT PLAN OF CARE.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2133-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910580, "text": " 12:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate for chf, pna\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman adm with GIB ileal varices. Now with hypoxia and\n fevers\n REASON FOR THIS EXAMINATION:\n pls evaluate for chf, pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GI bleed from ileal varices. Now with hypoxia and fever.\n\n Compared to yesterday's portable film, there is now new opacity in the right\n middle lobe, which may represent pneumonia. Bilateral pleural effusions may\n be slightly decreased. Vertical left basilar atelectasis now slightly\n obscures the descending aorta and some consolidation may be present here as\n well. Cardiac size is unchanged. A left subclavian central venous catheter\n has been placed and the tip is located at the level of the proximal superior\n vena cava. TIPS stent is identified in the right upper quadrant, new since\n yesterday's exam. Lumbar dextroscoliosis is noted.\n\n CONCLUSION:\n 1. New opacities in right middle lobe and left retrocardiac region, which\n could represent pneumonia or atelectasis.\n 2. Decreased pleural effusions.\n 3. Interim placement of left subclavian central venous catheter and TIPS\n stent.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910848, "text": " 8:58 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with 05/04 AP film showing RML and L retrocardiac opacities -\n atelectasis vs PNA\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: AP film shows right middle lobe and left retrocardiac\n opacities, evaluate for atelectasis versus pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: Left internal jugular venous access catheter appears in unchanged\n position with tip terminating in upper SVC. The heart size and mediastinal\n contours are within normal limits. There are bilateral pleural effusions,\n right greater than left, and bibasilar atelectasis, slightly increased from\n the previous examination. TIPS stent in place in right upper quadrant. No\n pneumothorax.\n\n IMPRESSION:\n 1. Bilateral pleural effusions and bibasilar atelectasis, slightly increased.\n No definite evidence of pneumonia.\n\n 2. Left internal jugular venous access catheter in satisfactory position.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910489, "text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: question of CHF vs pna\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman adm with GIB ileal varices. Now with hypoxia and\n fevers\n REASON FOR THIS EXAMINATION:\n question of CHF vs pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old female with GI bleed secondary to ileal varices.\n Evaluate for CHF versus pneumonia, now with hypoxia and fevers.\n\n\n AP CHEST RADIOGRAPH:\n\n Cardiac, mediastinal, and hilar contours are unchanged. The lung fields are\n clear. Bilateral small pleural effusions have slightly improved. No evidence\n of CHF or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2133-05-27 00:00:00.000", "description": "INSERT HEPATIC HUNT TIPS", "row_id": 910479, "text": " 7:18 AM\n TIPS Clip # \n Reason: needs TIPS. Attending physician: \n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OPTIRAY Amt: 210\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS NON-TUNNELED *\n * -51 MULTI-PROCEDURE SAME DAY US GUID FOR VAS. ACCESS *\n * -59 DISTINCT PROCEDURAL SERVICE CATH, TRANSLUM ANGIO NONLASER *\n * C1751 CATH ,/CENT/MID(NOT D STENT NOCOAT.NOCOVER W/ SYSTEM *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with cirrhosis and recurrent bleeding from ileocecal varices\n REASON FOR THIS EXAMINATION:\n needs TIPS. Attending physician: \n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 62-year-old woman with cirrhosis of the liver,\n recurrent bleeding from ileocecal varices, needs transjugular intrahepatic\n portosystemic shunt placement.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. , ,\n and Dr. . Dr. , the attending radiologist was present and\n supervising throughout the procedure.\n\n After risks and benefits were explained to the patient and patient's family,\n written informed consent was obtained. The patient was placed supine on the\n angiographic table. The bilateral necks were prepped and draped in the\n standard sterile fashion. A preprocedure timeout was performed to confirm the\n patient's name, procedure, and site. Using sterile technique, general\n anesthesia, and local anesthesia, an access was established to the right\n internal jugular vein using ultrasonographic guidance and micropuncture site.\n The access site was dilated and a 10-French vascular sheath was placed over\n the wire with the tip positioned in the superior vena cava under fluoroscopic\n guidance. A 5-French modified C2 catheter was then advanced through the\n sheath over the wire with its tip engaged into the hepatic vein under\n fluoroscopic guidance. The catheter was then advanced distally and venogram\n was performed. The catheter was then exchanged for a balloon occlusion\n catheter over the wire and CO2 portogram was performed after inflation of the\n balloon. This was done in the frontal and lateral projections. The portogram\n confirmed the position of the balloon catheter within the right hepatic vein.\n A TIPS puncture site was then advanced through the sheath into the hepatic\n vein and the branch of the right portal vein was entered after several\n attempts with the needle. A guide wire was then advanced into the main portal\n vein and a multihole straight catheter was then placed over the wire with the\n tip in the main portal vein. Pressure gradient was measured at the main\n portal vein, which was 34 mmHg. The venogram was performed through the\n catheter, which demonstrated multiple large collateral vessels. The liver\n parenchyma track was dilated with an 9-mm balloon with an inflation pressure\n up to 12 atm. A 10 mm x 94 mm Wallstent was then deployed, extending from the\n main portal vein into the hepatic vein. The stent was then dilated with 10-mm\n (Over)\n\n 7:18 AM\n TIPS Clip # \n Reason: needs TIPS. Attending physician: \n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n balloon. Pressure gradient decreased to 2 mmHg between the portal vein and the\n right atrium. The catheter was then repositioned into the main portal vein\n and followup venogram was performed. This demonstrated patent shunt, and\n decreased collateral vessels. The catheter and the sheath were then withdrawn\n into the IVC and then removed. Hemostasis was achieved by direct manual\n pressure for 15 minutes.\n\n By the request of anesthesiologist, a triple-lumen central line was placed\n before the procedure through left internal jugular vein using ultrasound\n guided puncture. Hard copy images were obtained before and after vascular\n access documenting vessel patency. The tip of the catheter is within the\n superior vena cava.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION:\n 1. Successful transjugular intrahepatic portosystemic shunt placement with\n reduction of a pressure gradient between portal vein and right atrium at\n approximately 2 mmHg after the TIPS placed.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-26 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 910424, "text": " 3:13 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with GIB and newly dx'd cirrhosis adm w/GIB, also with\n bilateral LE swelling,erythema,warmth\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: GI bleed and newly diagnosed cirrhosis with bilateral lower\n extremity swelling, erythema and warmth. Evaluate for DVT.\n\n COMPARISON: .\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound.\n\n FINDINGS: Grayscale, color, and Doppler images of the right and left common\n femoral, superficial femoral, and popliteal veins were obtained. Normal flow,\n compressibility, augmentation, and waveforms are demonstrated. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No deep venous thrombosis in right or left common femoral,\n superficial femoral, or popliteal veins.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910984, "text": " 10:28 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with 05/04 AP film showing RML and L retrocardiac opacities -\n atelectasis vs PNA, O2 sats slightly lower today\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of pneumonia.\n\n There has been no significant change since the prior film of , other\n than removal of the left jugular CV line. No pneumothorax. Bilateral pleural\n effusions and associated bibasilar atelectasis are again demonstrated and no\n new lung lesions are identified.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-05-25 00:00:00.000", "description": "Report", "row_id": 1418068, "text": "ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\n\ns: i feel like i have to urinate...the catheter is killing me\no: id: afeb. remains on vanco for cellulitus.\ncv: hr 90-100s sr. no vea. k and mag repleted. bp 85-105/50-60.\ngi: npo awaiting endoscopy. had no occult until after golytely prep restarted. pt had fluid o/p form ostomy and micu team decided they wished to have her take additional golytely. pt drank 2-3cups w clearing drg. then had obvious/ blood apprx 100cc. this stopped abruptly. and cont w green/brn fluid w some specs of red via ostomy. pt denies abd pain. has stopped golytely at present. micu team dicussed w liver service who are planning on doing a scope today. repeat hct stable at 31(28, 30)\non ivf at 75cc/hr.\nresp: no sob. rr 20s. bs cta. on ra.\ngu: c/o discomfort and foley dc'd. has been voiding, described some burning w urination.\nms: oob w assist. no c/o pain. visiting w husband and dtr.\na: gib. awaiting scope, hct stable. hemodynamocs stable.\np: follow ostomy o/p, check hct q6-8hrs. awaiting procedure. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-25 00:00:00.000", "description": "Report", "row_id": 1418069, "text": "CCU NPN 1530-1900\nS: \"I'm just glad its over.\"\n\nO: Please see careview for VS and additional data.\n\nCV: HR 90's NSR, no ectopy noted, NBP 90/50's, bilateral pedal pulses palp. Afternoon Hct 29.9.\n\nResp: Pt LS CTA, RR 22, O2 sats 94-98% on 3 L n.c.\n\nNeuro: Pt alert and oriented x 3, pleasant and cooperative with care.\n\nGI/GU: Pt scoped via ileostomy at approx 1730, see flowsheet for details; from varicose veins at surface of skin surrounding stoma; Ileostomy site red, dsg changed by ostomy nurse post procedure. Pt voiding via toilet per verbal report; remains NPO w/D51/2NS @75/hr infusing via r antcub - OK to start eating per GI service - team to review and write diet order\n\nID: T max 99.1.\n\nSocial: daughter/husband in to visit - updated by about results of scope, family appears very supportive\n\nA/P: 62 y/o female s/p colonoscopy. Continue to monitor pt abd, illeostomy site->monitor for further /stool. Continue to monitor hemodynamics, resp status, u/o, lytes. Continue to provide emotional support to pt.\n\nWritten by: RN/ RN\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-05-29 00:00:00.000", "description": "Report", "row_id": 1418079, "text": "CCU NPN 7a-7p MICU boarder\nS: \"I feel much better today. Do you think I'll be home by Sunday?\"\nO: please see carevue for complete assessment data.\nNo events.\nNEURO: no c/o pain, OOB->chair/commode all day, minimal assistance. No dizziness/lightheadedness. No focal neuro deficits.\n\nCV: stable off pressors, 1 250cc LR bolus for mild hypotension w/ effect. MAP 60-65 w/ CVP 6-10. HR 70s-100s NSR w/ no ectopy noted on tele, Hct stable.\n\nRESP: LSCTA upper lobes, fine bibasilar rales, using IS. RR 12-20. SpO2 92% on RA, >96% on 2L NC. No c/o dyspnea. Rare cough, nonproductive.\n\nGI/hepatic: Abd soft, nontender, midly distended. +BS, green/brown loose stool via ileostomy, cont OB (+). Appliance intact, stoma protruding, round and red. Tol heart healthy diet. LFTs wnl, Tbili trending down.\n\nGU/renal: foley removed d/t burning, voiding in bedside commode, CYU, even for 24hrs. Cr trending down.\n\nENDO: cont stress dose steroids day 2. BG slightly elevated, ordered FSs and RISS coverage.\n\nID: afebrile, cont zosyn, vanco trough pending (dose if under 15). WBC trending down.\n\nSKIN: w/d/i, warm and well perfused. No breakdown noted. PIV x 1 and LSC TLC placed in IR .\n\nSOC: family involved, no visits today.\n\nA: 62yo woman w/ newly dx'd ETOH cirrhosis presenting w/ GIB d/t portal HTN/ileal varicies. S/P TIPS w/ no further evidence of GIB, HD stable off vasopressors.\nP: f/u vanco level. Monitor BP-> goal MAP >60-65. Monitor for further via . Encourage diet and activity as tolerated, support to pt and family as needed. Anticipate c/o to floor.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-24 00:00:00.000", "description": "Report", "row_id": 1418066, "text": "ccu nursing progress note\npls see fhpa for details of admit\n\ns: i feel ok\no: pls see carevue flowsheet for compete vs/data/events\narrived from er at 8am w gib. 2nd unit of prbcs up and 2 to follow.\nalert, sleepy. able to follow commands. no c/o pain, appeared comfortable. denied abd pain and lightheadedness.\n id: low grade temp. started vanco for bilat le cellulitus. was prior on po keflex.\ncv: sr 80-100, no vea. bp 80s on admit, up to 95-105/40-60 in afternoon. rec'd 7l ivf in er as well as 2uints prbcs. aditional 2units prbcs infused here. hct 30.(20).\nresp: cta. no sob. weaning o2.\ngi: denies abd pain. ostomy functioning. drk brn w red o/p early on. ^'d o/p and clearing/diluting w golytely prep begun. then at 5:30pm had drk red blood w lrg clot into bag. emptied, no change in s/s. hct rechecked and unchanged. o/p now back to brn/, almost amber urine colored. has drank 1.5l golytely, now on hold eval ostomy o/p. plan had been for pt to rec 500cc to 2l golytely.\nhad been taking cl diet, npo after mn.\ngu: foley w good uop. remains >5l+\nms: alert, cooperative. no pain. husband visited, updated as to plan.\na: gib. 4units to stable hct.\nhypotension, resp to fluid/bld. cellulitus\np: follow ostomy o/p. golytley tonite to clear. follow hct q4hrs, next 8pm. contact team/gi w continued frankly bloody o/p. endoscopy tomorrow. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-25 00:00:00.000", "description": "Report", "row_id": 1418067, "text": "62 YR. OLD WOMAN WITH H/O ULCERATIVE COLITIS->S/P ILEOSTOMY. HX GIB REQUIRING 11U PRBC. ENDOSCOPY->ACTIVE AT OSTOMY SITE->\nSTITCHED, GRADE 1 ESOPHAGEAL VARICES, & NEW CIRRHOTIC LIVER CHANGES. SUTURES REMOVED 5D PTA. ->BRB PER OSTOMY. PRESENTED TO OSH->HCT 20\nTRANSFERRED TO ED->HCT 20 & SBP 90-110->7L IVF & 2U PRBC. NGT PLACED & LAVAGED (-). TRANSFERRED TO CCU AS MICU BORDER. HCT 23.5->\nRECEIVED ADDITIONAL 2U PRBC(TOTAL 4U PRBC). HCT 30. RECEIVING VANCO FOR BILATERAL LE CELLULITIS. SBP 80-100.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE.\n\nRESP: O2->2L NP. O2 SAT 94-96%. RR 17-21. BS CLEAR.\n\nCARDIAC: HR 88-98 SR, NO ECTOPY. BP 81-93/48-60. D5 1/2NS 75CC/HR.\nHCT 31.2->28. K 3.1 & MG 1.5->HO NOTIFIED & REPLACEMENT ORDERS TO BE WRITTEN. PT 17.1, PTT 37.6, INR 1.6, PLAT CT 201K.\n\nGI: CL. LIXS. NPO AFTER MIDNOC FOR ENDOSCOPY THIS AM. OSTOMY DRAINING YELLOWISH->BROWNISH CLEAR LIQUID.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR AMBER-YELLOW URINE. U/O 25-90CC/\nHR. BUN/CREAT 5/0.6.\n\nID: T 99.8->100.1(PO). CONT TO RECEIVE IV VANCO FOR BILAT LE CELLULITIS.\n\nPLAN: CONT. WITH Q4HR HCTS. GOAL>25.\n REPLACE LYTES AS ORDERED. RE-CHECK LYTES THIS EVENING.\n NPO FOR ENDOSCOPY THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-27 00:00:00.000", "description": "Report", "row_id": 1418074, "text": "Respiratory Care: Pt is s/p TIPS procedure. On current vent settings, and will attempt wean when more awake.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-28 00:00:00.000", "description": "Report", "row_id": 1418075, "text": "Respiraotry Care:\nPatient extubated yesterday prior to midnight, and placed on OFM, 50%.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-28 00:00:00.000", "description": "Report", "row_id": 1418076, "text": "CCU Nursing note\nS-\"Am I back in my room now. How did the procedure go?\"\nO-see flowsheet for additional details.\n\nEvents: Pt recieved from OR @ intubated on .25mcg neo, 60mcg propofol, and 50mcg sandostatin. Foley c inflated balloon D/C'd from . nurse appliance. Rt subclavian introducer for procedure d/c'd by IR fellow. Site stable and WNL simply covered by a bandaid. Initally afebrile, NSR/BP WNL, c normal green liquid output via . Extubated p difficulty @ 1130. Pt became tachycardic to 130s. EKG done -confirmed sinus tach. Pt p complaints of pain nor nausea. Became stiff c rigors. MICU team into evaluate. Temp up to 102.7. Dosed Tylenol x2, Zoysn, Vanc, and pt placed on cooling blanket. One incident 150cc Brick colored blood via @ 0500- notified and into evaluate. Currently requiring low dose neo for Maps >60.\n\nN-a/ox3, fentanyl IVP prior to extubation. No complaints of Nausea of pain. No deficits noted.\n\nCV-HR coming down to 90s-110 NSR-ST. Neo @ 1.0 mcg/kg for MAPs >60. CVP 8-10. Hct stable @ 29.6 s/p 2 units PRBC yesterday. Left subclavian TLC, 2 PIVs. + palpable pulses. Morning K 3.5/Mag 1.5 need repleated. Mixed Venous WNL @ 66.\n\nResp-Inceased O2 requirement s/p procedure. Currently on 70% face tent s sats 94-98%. Bibasliar faint crackles. +3.7L @ midnight from OR intake, +9.6L LOS. consider diuresing today. Encouraged C&DB. CXR done and confirmed +fluid status/bibaseler effusions.\n\nID-Tmax 102.7. Remains on cooling blanket-although turned off @ 0600. Last temp 98.8. Blood and urine cxs sent. Vanc continues for LE cellulitus. Zoysn added for gram - coverage s/p temp. WBC ^15.1.\n\nGI/GU/hepatic- S/P TIPs procedure. Green output via aside from 1 incident of bloody output. Denies any abd pain. Foley draining minimum adquate yellow urine. + fluid balance. Diuresis as BP tolerates?? IF BRB should occur again plan is to notify team and insert foley cath again to tamponade. Abd soft/distend. Slight bump BUN/crt.\n\nSkin-cellulitus LE. Sores on head-previuosly bleed when scratched-family asked for team to evaluate. otherwise intact.\n\nA/P-PMHx significant for collitus s/p illeostmy, ETOH abuse, cirrohsis c portal HTN, esophageal and superficial GI varcies, hypothyroidism. readmitted after reaccurance of BRB per . Endoscopy confirmed cause-s/p TIPS procedure . Monitoring output/abdomen. Continue to monitor ??bacterima-temp/titrate neo. Attempt to wean O2. Repleate lytes. support and update pt and family per interdisiplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-28 00:00:00.000", "description": "Report", "row_id": 1418077, "text": "CCU NPN 7a-7p\nS: \"I didn't realize how sick I was last night...\"\nO: please see careuve for complete assessment data\nNEURO: A&Ox 3, easily arousable. MAE, assists w/ turning, standing @ bedside w/ minimal assistance. No c/o pain, no focal neuro deficits noted.\n\nCV: Cont to require pressor support, MAP 50-69. Neo changed to levophed; maintaining MAP >65. CVP low () 250cc NS bolus x 1 w/ effect. Distal pulses palp, extremities warm and well perfused, lactate up slightly 1.7. Hct stable.\n\nRESP: SpO2 > 97% on 2L NC, LSCTA, slightly diminished L>R. CXR w/ bilat pelural effusions and ? PNA, mild CHF. No cough.\n\nGI/heptaic: Abd soft, disteded, nontender. +BS, cont liquid green OB (+) stool from ilestomy. Appliance changed w/ some noted from friable stoma tissue, stoma round and beefy red. No further BRB per s/p TIPS, cont octreotide gtt. Hepatic US done to eval patencey of TIPS. Tol low sodium diet after US completed, denies nausea.\n\nGU/renal: Foley draining CYU, borderline low @ times; fluid balance even for 24hrs. BUN/Cr trending up.\n\nENDO: stim-> started hydrocort/fludrocort\n\nID: Afebrile, WBC cont to climb. Cont vanco, awaiting ID approval for zosyn.\n\nSKIN: w/d/i, PIV x 1, LSC TLC patent and intact. No breakdown noted.\n\nSOC: son called, family very supportive.\n\nA: newly dx'd ETOH cirrhosis and portal/ileal varicies/HTN w/ GIB requiring multiple uPRBCs/fluid. Stable s/p TIPS w/ no further BRB noted via , cont to require pressor support.\nP: Per multidiciplinary rounds cont levophed to maintin MAP > 65. Goal CVP 8-12. Monitor u/o. Cont to monitor temps w/ rising WBC, cont abx. Support to pt/family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-29 00:00:00.000", "description": "Report", "row_id": 1418078, "text": "CCU NPN 1900-0700\nS: \" I'm feeling good \"\nO: pt. without c/o discomfort or pain. dangling at bedside and ate small dinner family brought in. asking for ambien for sleep with good result. wakes easily and approp.\n\nHR 90-100ST when awake and talking with family. down to 70-80's SR when asleep. NO VEA. MAP 67-77. 95/55-103/62. levo weaned to .043mcq/k/min by 0500. HO aware. goal MAP is still 65.\n\nLS clear. 2lnc sats 92-97%. denies SOB. appearing slightly dyspneic with exertion.\n\nfoley draining clear dk yellow urine. 40-50cc/hr. neg. 500cc for but pos. 9L LOS\n\nABD slightly distended, soft. BS present. colostomy bag emptied for large amt. of grean liq/mixed with solid. no blood. HCT at 2100 25.\n\nTM 99.7 -99po. tylenol x1. zosyn started. vanco level trough for 2200 dose - 25. dose given. HO aware.\n\nA/P: stable night without c/o. slept with ambien. no further . check vanco trough prior to next dose. hold vanco dose until level back. contin. to wean levo to off for MAP 65. OOB today as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-27 00:00:00.000", "description": "Report", "row_id": 1418072, "text": "CCU Nursing Note\nS-\"I hope the procedure happens tomarrow.\"\nO-see flowsheet for additional details.\n\nN-a/ox3, OOB to commode with steady gait, no focal deficits noted.\n\nCV-HD stable. NSR 70s-90s c SBP 80s-100/MAP WNL. +pulses. Right AC IV D/c'd. 20g placed in rt forearm-2PIVS. +1 edema in LE c cellulitus. HCT stable.\n\nResp->95% on RA. While asleep sats drop to low 90s-2L NC while asleep. LSCTA.\n\nGI/GU/Hepatic-illeostomy output remains guic + yet brown/green in color, liquid consistency. ostomy site beefy red. Pouch intact-pt self care with. NPO since midnight awaiting TIPS procedure. Voiding CYU. Sandostatin continious as ordered.\n\nID-Temp @ 0000 100.6. MD notified. Blood and urine cxs sent. Tylenol x1 dosed. Continues on Vanc for LE cellulitis. BLE red c 1+edema.\n\nSkin-areas on scalp which pt scratch and caused to bleed. subsided previous shift. pt states this has been a long time problem. Team aware. LE cellulitus. Otherwise intact.\n\nA/P-62y.o. female admitted c repeat BRB per ostomy. Endosocopy revealed Varcies resulting from portal HTN. PMHx significant for colitis s/p illeostomy, ETOH abuse, liver cirrohsis. Awaiting TIPS procedure in am. F/U am labs. Continue to support pt concerning procedure and update per interdisiplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-27 00:00:00.000", "description": "Report", "row_id": 1418073, "text": "CCU NSG NOTE: ALT IN GI/GIB\nS: \"I feel awful\"\nO: For complete Vs see CCU flow sheet.\nGI: Pt stable draining green stool from ostomy that was G+ until 2pm when she rapidly put out 1050 of BRB. She became dizzy and was assisted back to bed. GI was there and inserted catheter into stoma and blew up balloon to tampanade . She received IVF then 1u prbc over 45min and then albumen. She conts on sandostatin at 50 mcg/hr. She had been receiving D51/2NS at 75cc/hr. AT ~1500 she went to IR for TIPs proceedure.\nHEME: Crit drawn shortly after episode was 26.1, down from 28.7. INR 1.5.\nCV: Pt had been hemodynamically stalble with HR in 70-80s and BP low in mid 80s-100/50-60s. Wihg episode BP was down in 70s, but up to low 90s with fluid and blood.\nRENAL: Pt voiding in commode. Foley inserted prior to going to IR.\nRESP: PT has BBR. ENcouraged to use IS. Sating between 94-98% on RA, later 99% on 2L NP.\nID: Pt conts on vanco for cellulitis. Afebrile.\nSKIN: Bilateral lower extremity cellulitis remains reddened and mildly\n warm, but greatly improved.\nMS: PT remains A & O X 3. Was in excellent spirits until rebleed.\nA: REbleeding. Went to IR at 1500\nP: Pt will return from PACU once recovered.\n" }, { "category": "Radiology", "chartdate": "2133-05-28 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 910643, "text": " 12:56 PM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: patency of the TIPS\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with h/o UC s/p colectomy, newly dx'd cirrhosis and ascites\n with LGF - need diagnostic para.\n REASON FOR THIS EXAMINATION:\n patency of the TIPS\n ______________________________________________________________________________\n FINAL REPORT\n SCAN OF RIGHT UPPER QUADRANT INCLUDING DOPPLER ASSESSMENT OF HEPATIC\n VASCULATURE.\n\n CLINICAL DETAILS: Day 1 post-TIPS insertion. Liver cirrhosis.\n\n FINDINGS:\n The liver is normal in size, no focal lesions. No intrahepatic biliary\n dilatation. The TIPS stent is demonstrated between the posterior branch of\n the right portal vein and right hepatic vein. The stent appears patent with\n wall-to-wall flow on color Doppler. Doppler interrogation along the stent\n shows a velocity of 71 cm per second in its proximal portion, an elavated\n velocity of 210 and 256 cm in the mid portion and 142 cm at the distal end.\n These velocities above 200 cm per second require close followup.\n Main portal vein is patent with a velocity of 41 cm per second. There is\n normal hepatopetal directional flow in the main and right portal vein towards\n the TIPS stent.\n Inferior vena cava appears patent on color Doppler as is the right hepatic\n vein. Normal arterial waveform in the left hepatic artery.\n\n Small amount of intra-abdominal ascites around the liver in the right upper\n quadrant.\n\n CONCLUSION:\n\n 1. Patent TIPS stent with expected hepatopetal directional flow in the main\n portal vein. Elevated velocities in the mid portion of the TIPS stent over\n 200 cm per second. Short interval followup with Doppler is advised.\n\n 2. Small amount of intra-abdominal ascites.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-05-30 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 910915, "text": " 3:41 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: pls evaluate for interval change with Dopplers\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with h/o UC s/p colectomy, newly dx'd cirrhosis and\n ascites, now s/p TIPS with elevated velocities in the TIPS stent.\n REASON FOR THIS EXAMINATION:\n pls evaluate for interval change with Dopplers\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with status post TIPS with elevated velocities on\n prior study.\n\n COMPARISON: .\n\n TIPS ULTRASOUND: 2D, color flow, and Doppler examination of the abdomen was\n performed and compared with . There is a TIPS stent in the\n posterior branch of the right portal vein and right hepatic vein. The stent\n appears patent with wall-to-wall color flow on Doppler exam. Doppler\n interrogation along the stent shows velocity of 107 cm per second in the\n proximal portion, 116 to 160 cm per second in the mid portion and 129 cm per\n second in the distal portion. These velocities are appropriate and have\n decreased in comparison to . The main portal vein is patent with\n velocity of approximately 59 cm per second. There is normal hepatopetal\n directional flow in the main and right portal vein toward the TIPS stent. The\n inferior vena is patent. There is appropriate flow in the main hepatic and\n left hepatic veins. There is normal arterial waveform in the common hepatic\n and anterior right hepatic arteries. There is a small amount of intra-\n abdominal ascites around the liver in the right upper quadrant.\n\n IMPRESSION:\n 1. Patent TIPS stent with appropriate velocities ranging from 107 to 160 cm\n per second. This is improved in comparison to the prior study.\n\n 2. Small amount of intra-abdominal ascites.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-05-26 00:00:00.000", "description": "Report", "row_id": 1418070, "text": "CCU Nursing note\nS-\"I haven't eaten for 4 days. I just wanna get this procedure over with.\"\nO-see flowsheet for additional details.\n\nN-a/ox3, MAE, OOB to commode c 1 assist, steady gait. No deficits noted.\n\nCV-NSR 80s-90s c baseline SBP 70s-90s. 2 PIVs. IVF @ 75cc/hr while NPO. AM HCT 28.4. HD stable.\n\nResp-2-4L via NC during night-mouth breather. LS clear throughout. Encourage C&DB.\n\nHepatic-Awaiting TIPS procedure today. s/p endoscopy revealed BRB via ostomy due to varicies from portal hypertension. Octerotide acetate continious infusion as ordered.\n\nGI/GU-No observed this shift. Ostomy output now green-remains guic +. Denies pain. voiding without difficulty adequte CYU. remains NPO since midnight for TIPS procedure. +6.3L LOS. Ostomy dsg changed by skin care nurse. otherwise pt self care c ostomy.\n\nID-continues on vanc for LE cellulitus c Reddness and +1edema. afebrile.\n\na/p-62y.o female h/o colitius c ostomy placement 30 years ago per pt. Hypothyroid, ETOH abuse, Cirrhotic liver. Recurrent BRB from ostomy resulting from portal hypertension. NPO and awaiting TIPS procedure today. Follow Hct, repleate lytes. pt and update per interdisiplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2133-05-26 00:00:00.000", "description": "Report", "row_id": 1418071, "text": "CCU NPN 0700-1900\nS: \" I just want to get this procedure over with.\"\n\nO: Please see careview for VS and additional data.\n\nCV: HR 80-90's NSR, no ectopy noted. NBP 89-101/58-71. This am->K 3.9, phos 2.4-> K phos finished infusing this shift. Evening HCt to be drawn. Bilateral pedal pulses palp.\n\nResp: LS CTA, RR 16-24, O2 sats 94-96% on room air. Pt sleeping this afternoon with O2 sats 91-92 on room air-> placed on 2 L n.c with O2 sats >96%.\n\nNeuro: Pt alert and oriented x 3, MAE, steady OOB to commode with 1 assist/supervision. Pt tearing during conversation with radiology MD's for consent TIPS procedure, pt verbalized concern about potential risks for surgery with MD and RN's, emotional support given, pt calm, pleasant and cooperative with care.\n\nGI/Hepatic/GU: Pt abd soft, + BS x 4, pt with minimal amts ostomy output liquid brown, see flowsheet, ostomy site pinkish red. Pt continues on sandostatin 50 mcg/hr, vitamin K given this am as ordered. Pt scheduled for TIPS procedure, NPO throughout shift-> procedure changed to tomorrow-> pt presently ordering dinner, pt to be NPO after midnoc in anticipation of TIPS procedure tomorrow. Dr. verbalized to RN he will be up to discuss rescheduling with pt. Pt voiding adequate amts clr yellow u/o via commode, see flowsheet.\n\nID: Pt afebrile, continues on vanco, BLE red with 1+ edema.\n\nSkin: Pt noted to have some blood in hair this am, per pt-pt has sores on head that from scratching and stress can bleed. Per pt-pt has had this condition for years.\n\nA/P: 62 y/o female s/p illeoscopy , no further noted, BLE US done, awaiting TIPS procedure for tomorrow. Continue to monitor pt hemodynamics, resp status. Monitor for , u/o stool out. Continue to provide emotional support to pt. Awaiting further POC per MICU Team.\n" } ]

[ { "category": "Echo", "chartdate": "2141-04-27 00:00:00.000", "description": "Report", "row_id": 62998, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Congenital heart disease. Hypertension. Left ventricular function. Mitral valve disease.\nStatus: Inpatient\nDate/Time: at 17:36\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\nin the body of the LAA. All four pulmonary veins identified and enter\nthe left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast\nor thrombus in the body of the RA or RAA. PFO is present. The IVC is normal in\ndiameter with appropriate phasic respirator variation.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH. Normal LV cavity size. Severe regional LV systolic\ndysfunction. Mild global LV hypokinesis.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; basal inferior - hypo; basal inferolateral - hypo; mid\ninferolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex\n- hypo; lateral apex - hypo; apex - hypo; remaining LV segments contract\nnormally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal aortic root diameter. Simple atheroma in aortic\nroot. Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate thickening of mitral valve chordae. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure.\n\nConclusions:\nThe left atrium is moderately dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium or left atrial appendage. No\nspontaneous echo contrast or thrombus is seen in the body of the right atrium\nor the right atrial appendage. A patent foramen ovale is present. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. There is severe regional left ventricular systolic dysfunction.\nThere is mild global left ventricular hypokinesis. Resting regional wall\nmotion abnormalities include severely hypokinetic septum, mid anterior and\nlateral wall and akinetic apex.. The remaining left ventricular segments\ncontract normally. Right ventricular chamber size and free wall motion are\nnormal. The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque. There are simple atheroma in the\naortic root. There are simple atheroma in the ascending aorta. There are\nsimple atheroma in the descending thoracic aorta. There are three aortic valve\nleaflets. The aortic valve leaflets (3) are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are moderately thickened. There is moderate thickening of the mitral\nvalve chordae. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2141-04-28 00:00:00.000", "description": "Report", "row_id": 119043, "text": "Sinus rhythm\nLeft axis deviation\nConsider anteroseptal infarct - age undetermined\nLeft ventricular hypertrophy\nSince previous tracing of , no significant change\n\n" }, { "category": "Radiology", "chartdate": "2141-04-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915238, "text": " 8:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Locate line tip and r/o pneumothorax.\n Admitting Diagnosis: INFECTED LEFT LEG ULCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with new CVL\n REASON FOR THIS EXAMINATION:\n Locate line tip and r/o pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right IJ line placed, check position.\n\n CHEST AP: The tip of the right IJ line lies in the lower portion of the SVC.\n There is no evidence of pneumothorax. The lung fields are clear.\n\n IMPRESSION: No pneumothorax. Line in satisfactory position.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915464, "text": " 9:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumonia\n Admitting Diagnosis: INFECTED LEFT LEG ULCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman peripheral bypass w/ fever\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 59-year-old woman with peripheral bypass and fever. Evaluate for\n pneumonia.\n\n FINDINGS: The left-sided IJ central venous catheter is unchanged in position.\n The cardiac silhouette and mediastinum are normal. There is a persistent\n small right-sided pleural effusion. There is no focal consolidation or overt\n pulmonary edema.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2182-05-01 00:00:00.000", "description": "OUTSIDE FILMS READ ONLY", "row_id": 1132435, "text": " 10:22 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABDOMEN W/O CONTRAST; OUTSIDE FILMS READ ONLY\n CT PELVIS W/O CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: please evaluate CT torso from OSH for necrotizing pancreatit\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with pancreatitis\n REASON FOR THIS EXAMINATION:\n please evaluate CT torso from OSH for necrotizing pancreatitis\n ______________________________________________________________________________\n WET READ: SHfd WED 10:48 PM\n Necrotizing pancreatitis. 8cm peripanc fluid collection(? early pseudocyst)\n infection not excluded. severe surrounding inflammatory chcange extending to\n colon splenic flexure.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Necrotizing pancreatitis.\n\n COMPARISON: None.\n\n TECHNIQUE: CT images obtained at outside hospital at \n were uploaded on PACS. These images include axial non-contrast images\n of the abdomen and pelvis followed by axial post-contrast images of the\n abdomen and pelvis with coronal and sagittal reformats.\n\n FINDINGS: Lung bases demonstrate atelectatic-chronic scarring changes. The\n heart is not enlarged. There is no pericardial effusion. Liver is\n unremarkable. The patient is status post cholecystectomy. Spleen measures 14\n cm in length, which is enlarged. Both adrenals appear normal. Both kidneys\n are in normal anatomic location and demonstrate symmetric enhancement. There\n is a too small to characterize hypodensity in the right kidney. The pancreas\n demonstrates areas of lack of enhancement compatible with necrosis with\n adjacent inflammatory changes. A 6.3 x 7.4 cm area of somewhat loculated\n fluid is seen adjaent to the pancreas. The splenic vein appears diminutive\n but grossly patent. There is no evidence of portal vein thrombosis. There is\n also free fluid surrounding the liver and extending into the paracolic\n gutters. Fat stranding surrounding the colon at the splenic flexure likely\n represents extension of inflammation from the pancreas. Abdominal aorta and\n iliac vessels are unremarkable. There are a few subcentimeter abdominal and\n retroperitoneal lymph nodes with no evidence of lymphadenopathy by size\n criteria. There is no bowel obstruction. Normal appendix is seen in the\n right lower quadrant.\n\n The uterus and rectum appear unremarkable. The urinary bladder contains a\n Foley catheter and otherwise appears unremarkable.\n\n OSSEOUS STRUCTURES: Degenerative changes of the spine are moderate to severe.\n There is no bony lesion to suggest malignancy or infection.\n\n IMPRESSION:\n 1. Necrotizing pancreatitis with 6.3 x 7.4 cm area of loculated fluid adjacent\n to the pancreas. While this may represent inflammatory changes from severe\n (Over)\n\n 10:22 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABDOMEN W/O CONTRAST; OUTSIDE FILMS READ ONLY\n CT PELVIS W/O CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: please evaluate CT torso from OSH for necrotizing pancreatit\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pancreatitis or developingpseudocyst, infectious process/developing abscess\n can not be excluded.\n\n 2. Diminutive splenic vein.\n\n 3. Splenomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2182-05-06 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1133144, "text": " 3:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval dobhoff placement.\n Admitting Diagnosis: NECROTIZING PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with necrotizing pancreatitis, resp failure s/p extubation\n and dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with necrotizing pancreatitis and respiratory\n failure status post Dobbhoff placement.\n\n COMPARISON: Chest radiographs from .\n\n Single AP supine radiograph demonstrates a Dobbhoff with its weighted tip\n within the mid stomach.\n\n" }, { "category": "Radiology", "chartdate": "2182-05-01 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1132429, "text": " 9:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with s/p ett\n REASON FOR THIS EXAMINATION:\n please eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Endotracheal tube placement.\n\n COMPARISON: Chest radiograph from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Study is limited due to low lung volumes.\n The patient is rotated to the right. Endotracheal tube is about 3 cm above\n the carina. Lungs are clear with no evidence of focal consolidation or overt\n pulmonary edema. There is no pneumothorax or pleural effusion. Heart is not\n enlarged. Mediastinal prominence is stable.\n\n IMPRESSION: Limited study due to low lung volumes and patient rotation to the\n right. Superior mediastinum remains prominent. Endotracheal tube in\n appropriate position.\n\n" }, { "category": "Radiology", "chartdate": "2182-05-02 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1132547, "text": " 2:22 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new line placement RIJ\n Admitting Diagnosis: NECROTIZING PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with new line\n REASON FOR THIS EXAMINATION:\n new line placement RIJ\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: New line placement.\n\n FINDINGS: New right internal jugular vascular catheter terminates within the\n mid superior vena cava, with no visible pneumothorax. Exam is otherwise\n likely not appreciably changed allowing for marked rotation of the patient on\n the current study.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-06 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1133174, "text": " 6:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval dobhoff placement.\n Admitting Diagnosis: NECROTIZING PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with complaining of discomfort with tube feeds\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement.\n ______________________________________________________________________________\n WET READ: ENYa MON 10:25 PM\n Weighted enteric tube with tip in the gastric antrum/pylorus area.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For Dobbhoff placement.\n\n FINDINGS: In comparison with the earlier study of this date, the Dobbhoff\n tube again extends to the distal stomach. Right IJ catheter extends to mid\n portion of the SVC. No evidence of acute cardiopulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-03 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1132732, "text": " 3:18 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please further evaluate mediastinum\n Admitting Diagnosis: NECROTIZING PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with pancreatitis, respiratory failure; widened mediastinum\n noted on CXR\n REASON FOR THIS EXAMINATION:\n please further evaluate mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Wide mediastinum.\n\n FINDINGS: The patient is markedly rotated towards the right. This limits\n assessment of the mediastinum, but it does not appear wider than on the recent\n study allowing for this factor. Overall appearance of the chest is relatively\n similar except for worsening bibasilar atelectasis and slight increase in\n bilateral small pleural effusions. Repeat non-rotated radiograph may be\n helpful to more fully assess the mediastinum when the patient's condition\n allows.\n\n\n" }, { "category": "ECG", "chartdate": "2182-05-02 00:00:00.000", "description": "Report", "row_id": 233869, "text": "Sinus bradycardia. Low voltage in the precordial leads. Compared to the\nprevious tracing low voltage is new.\n\n" }, { "category": "ECG", "chartdate": "2182-05-02 00:00:00.000", "description": "Report", "row_id": 233870, "text": "Sinus rhythm. Compared to the previous tracing heart rate is reduced.\nOtherwise, there is no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-05-01 00:00:00.000", "description": "Report", "row_id": 233871, "text": "Sinus tachycardia. Borderline left axis deviation. Possible left anterior\nfascicular block. Compared to the previous tracing of heart rate is\nincreased. Otherwise, no diagnostic change.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2115-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888582, "text": " 4:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess placement of central line\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p knee surgery with blood loss and hypotension. S/p\n placement of R IJ triple lumen\n REASON FOR THIS EXAMINATION:\n please assess placement of central line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , AT 1747 HOURS\n\n COMPARISON: Previous study of earlier the same date at 0104 hours.\n\n INDICATION: Line placement.\n\n A right internal jugular vascular catheter terminates in the lower superior\n vena cava, with no evidence of pneumothorax. An endotracheal tube remains in\n satisfactory position. Cardiac and mediastinal contours are stable. There is\n left lower lobe atelectasis and a small left effusion, possibly slightly\n improved in the interval. A new small right pleural effusion has developed in\n the interval.\n\n IMPRESSION: Central venous catheter in satisfactory position, with no\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888450, "text": " 5:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: et tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with\n REASON FOR THIS EXAMINATION:\n et tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:19 P.M.\n\n HISTORY: ET tube placement.\n\n IMPRESSION: AP chest compared to .\n\n New left lower lobe consolidation is probably atelectasis, given leftward\n mediastinal shift. There is accompanying small left pleural effusion. No\n pneumothorax. Heart size normal. Tip of the endotracheal tube is at the\n sternal notch, 5 cm above the carina in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-05 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 888744, "text": " 4:11 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: 70 year old woman s/p B TKR w/ clinical suspicion for venous\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p B TKR w/ suspicion for venous bleed into knee\n REASON FOR THIS EXAMINATION:\n 70 year old woman s/p B TKR w/ clinical suspicion for venous bleed into knee.\n Please keep both knees in varus and slightly flexed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post bilateral total knee replacement with clinical suspicion\n for venous bleed into the knee.\n\n COMPARISON: None.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler son\n of both common femoral, both superficial femoral, and both popliteal veins\n were performed. There was lack of compressibility within the right common\n femoral, right superficial femoral, and right popliteal veins. Additionally,\n partially-occlusive thrombus was identified within the right common femoral\n vein and right popliteal vein. Normal color flow, however, was demonstrated\n within the right common femoral vein and right superficial femoral vein.\n\n Normal compressibility, waveforms, color flow, and augmentation was\n demonstrated within the left lower extremity.\n\n There is no evidence of hematoma within the right knee.\n\n IMPRESSION:\n\n 1. Partially-occlusive thrombus within the right common femoral and right\n popliteal veins.\n\n 2. No deep venous thrombosis within the left upper extremity.\n\n 3. No evidence of a hematoma within the right knee.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2115-12-11 00:00:00.000", "description": "B CTA LOWER EXT W/&W/O C & RECONS BILAT", "row_id": 889523, "text": " 3:05 PM\n CTA LOWER EXT W/&W/O C & RECONS BILAT; CTA PELVIS W&W/O C & RECONSClip # \n CT 150CC NONIONIC CONTRAST\n Reason: 70 year old woman s/p B TKR. Thigh hematoma, ? arterial vers\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p B TKR\n REASON FOR THIS EXAMINATION:\n 70 year old woman s/p B TKR. Thigh hematoma, ? arterial versus venous bleed.\n Please evaluate w/ CTA and CTV.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PAOb WED 6:12 PM\n Compared to previous CT.\n\n Hyperdense hematomas in lower left rectus femoris,haematoma in the left\n suprepatellar bursa area and hematoma suprolateral to the right knee joint are\n stable in size compared to the previous CT.\n\n No pseudoaneurysms or active extravasation of contrast on CT.\n\n Right CFV/SFV Deep venous Thrombosis (known and patient has had an IVC filter\n placed).\n\n\n ______________________________________________________________________________\n FINAL REPORT\n MULTIDETECTOR CT SCAN OF THE LOWER EXTREMITIES (CT ANGIOGRAM PROTOCOL\n INCLUDING ARTERIAL,VENOUS AND PRECONTRAST PHASE).\n\n Multiplanar reconstructions in the sagittal and coronal plane, MIP and volume-\n rendered images of the lower limb arterial anatomy are also included.\n\n CLINICAL DETAILS: Post-bilateral knee replacements. Multiple postoperative\n transfusions and hematomas around the site of the recent knee surgery on\n preceding imaging. Evaluate for interval change or active bleeding.\n\n Comparison is made to previous imaging including CT scan of .\n Due to difficult upper limb venous access, a left lower limb venous access\n point was used.\n\n CT ANGIOGRAM FINDINGS:\n\n The included portion of the right and left inferior external iliac arteries,\n common femoral, superficial femoral, and profunda femoral arteries appear\n normal. Visible portion of the popliteal arteries also appears normal, but\n there is significant streak artifact from the knee prosthesis at the level of\n the knee joints. No evidence of pseudoaneurysm or active extravasation of\n contrast on the current CT.\n\n A number of hematomas around the site of recent right and left knee joint\n surgery which are stable in size compared to . On the left\n (Over)\n\n 3:05 PM\n CTA LOWER EXT W/&W/O C & RECONS BILAT; CTA PELVIS W&W/O C & RECONSClip # \n CT 150CC NONIONIC CONTRAST\n Reason: 70 year old woman s/p B TKR. Thigh hematoma, ? arterial vers\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n side, these include one anteriorly in the left suprapatellar bursa region\n which is hyperdense in keeping with recent hematoma measuring up to 8.6 cm\n transverse. More cranially in the inferior portion of the left rectus femoris\n muscle, there is a heterogenous hematoma unchanged in size measuring up to \n cm transverse by up to 4 cm AP which contains an area of hypodensity along its\n lateral aspect.\n\n On the right side, recent hyperdense hematoma along the inferior aspect of the\n vastus lateralis just above the level of the knee joint which is stable in\n size measuring up to 5.6 cm AP by approximately 4.9 cm transverse.\n\n Some generalized edema is noted in the subcutaneous tissues mainly in the left\n thigh area.\n\n The delayed phase images show non-occlusive thrombus within the right\n lower limb involving the common femoral, right superficial femoral, and part\n of the right popliteal vein.\n\n The alignment of the right and left knee joint prosthesis appears normal.\n\n CONCLUSION:\n\n 1. Bilateral hematomas around the recent knee joint surgery, larger on the\n left side. These are stable compared to recent CT. No evidence of\n pseudoaneurysm or active extravasation of contrast on the CTA.\n\n 2. Right lower limb deep venous thrombosis extending to the upper common\n femoral vein level. The patient has had filter placed.\n\n Findings discussed with Dr. .\n\n" }, { "category": "ECG", "chartdate": "2115-12-08 00:00:00.000", "description": "Report", "row_id": 211217, "text": "Sinus rhythm\nLow QRS voltage\nDiffuse nonspecific T wave abnormalities\nSince previous tracing of , sinus tachycardia absent and further T wave\nchanges now seen\n\n" }, { "category": "ECG", "chartdate": "2115-12-06 00:00:00.000", "description": "Report", "row_id": 211218, "text": "Sinus tachycardia\nAtrial premature complex\nLow QRS voltage\nModest diffuse low amplitude T waves\nFindings are nonspecific but clinical correlation is suggested\nSince previous tracing of , changes as described now present\n\n" }, { "category": "Radiology", "chartdate": "2115-12-24 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 891113, "text": " 9:25 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess swallowing\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with dysphagia\n\n REASON FOR THIS EXAMINATION:\n assess swallowing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with dysphagia.\n\n Comparison was made to the video swallow study of .\n\n VIDEO OROPHARYNGEAL SWALLOW FLUOROSCOPIC STUDY: A video oropharyngeal swallow\n fluoroscopic study was performed in collaboration with the speech pathology.\n Thin liquid, nectar thick liquid, puree consistency barium 1 cookie coated\n with barium, and one barium pill were administered. In the oral phase, the\n patient demonstrated premature spillover into the vallecula with thin liquids.\n Mild amounts of residue were appreciated in the valleculae in the pharyngeal\n phase. The laryngeal valve closure was mildly to moderately reduced. Mild\n aspiration occurred during the swallow with sips of thin liquid due to the\n poor valve closure. Spontaneous reflexive cough effectively cleared the\n aspiration. Chin tuck maneuver was effective in preventing aspiration with\n cup sips of thin liquids but not with straw sips of thin liquid.\n\n IMPRESSION: Mild premature spillover and mild aspiration. Reduced valve\n closure. Chin tuck was effective in preventing aspiration with sips of thin\n liquid but not with straw sips of thin liquid. For further details of the\n study, please repeat the speech pathology report under CareWeb.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-27 00:00:00.000", "description": "B KNEE (2 VIEWS) BILAT", "row_id": 891563, "text": " 9:43 AM\n KNEE (2 VIEWS) BILAT Clip # \n Reason: please do bilateral AP, lateral & sunrise views of patella.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p B TKR\n\n REASON FOR THIS EXAMINATION:\n please do bilateral AP, lateral & sunrise views of patella. Right sided XR need\n to be done with brace in place.\n ______________________________________________________________________________\n FINAL REPORT\n THREE VIEWS OF THE LEFT KNEE, TWO VIEWS OF THE RIGHT KNEE\n\n INDICATION: Bilateral total knee replacements.\n\n FINDINGS:\n\n RIGHT KNEE: Comparison with prior exam dated . Two views of\n the right knee reveal a total knee prostheses in position, with cemented\n femoral and tibial components. The tibial component is held in position with\n two screws, one of which is seen passing through the medial proximal tibial\n cortex. There is no evidence of hardware failure. Patient is status post\n patellar resurfacing. There is a large suprapatellar effusion, and soft\n tissue swelling.\n\n LEFT KNEE: Three of the left knee reveal cemented femoral and tibial\n components in appropriate position, as well as evidence of patellar\n resurfacing. There is a large suprapatellar effusion, and overlying soft\n tissue swelling. Several calcified loose bodies are seen within the posterior\n joint space, as identified on the preoperative study.\n\n IMPRESSION: Bilateral total knee replacements as described, with bilateral\n suprapatellar effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888632, "text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for presence of effusions, infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p knee surgery with blood loss and hypotension.\n\n REASON FOR THIS EXAMINATION:\n please eval for presence of effusions, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:57 A.M. ON \n\n HISTORY: Knee surgery. Blood loss and hypotension.\n\n IMPRESSION: AP chest compared to postoperative films on and\n preoperative film from :\n\n Widening of the superior mediastinum at the thoracic inlet suggests volume\n overload to central venous engorgement. Small bilateral pleural effusions and\n left lower lobe atelectasis are unchanged from . ET tube and\n right internal jugular line are in standard placements respectively. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 890242, "text": " 9:57 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: RUQ to assess liver parenchyma, also assess flow to r/ \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman w/ coagulopathy, increased LFTs\n REASON FOR THIS EXAMINATION:\n RUQ to assess liver parenchyma, also assess flow to r/o thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right upper quadrant pain.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture, and\n there are no focal hepatic masses. There is no intra- or extrahepatic biliary\n ductal dilatation. The gallbladder is normal without stones or wall edema.\n The common bile duct is normal measuring 5 mm. The main portal vein is patent\n with appropriate direction of flow. The right kidney is normal in appearance,\n without hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-05 00:00:00.000", "description": "INITAL 2ND ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 888706, "text": " 1:19 PM\n -LAT FEMORAL Clip # \n Reason: ? bleeding\n Contrast: OPTIRAY Amt: 135\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER EXT BILAT A-GRAM *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 100 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with bilat TKRs with decreasing Hct and prior 2-3L blood loss\n in OR + rt LE swelling.\n REASON FOR THIS EXAMINATION:\n ? bleeding\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent bilateral total knee replacement with much bleeding, episode\n of hypotension, decreased hematocrit, which has been treated by transfusions.\n Increased right lower extremity swelling. Evaluate for bleeding.\n\n PHYSICIANS: The procedure was performed by doctors and \n with Dr. , the attending radiologist, being present and\n supervising throughout the procedure.\n\n PROCEDURE: Following written informed consent from the patient's daughter,\n , the patient was positioned supine on the angiography table.\n Preprocedure timeout was performed to confirm patient, procedure, and site.\n Standard sterile prep and drape of both inguinal regions and the in situ left\n femoral arterial line. Initial fluoroscopy confirmed that the in situ left\n femoral arterial line was in the expected region of the left common femoral\n artery and that the puncture site was superimposed on the femoral head. A\n 0.018-inch guidewire was advanced through the arterial line into the left\n common iliac artery using fluoroscopic guidance. The in situ femoral art line\n was exchanged for a micropuncture sheath, which was used to upsize the\n guidewire to a 0.035 inch guidewire, which was advanced into the aorta under\n fluoroscopic guidance. The micropuncture sheath was then exchanged for a 5-\n French vascular sheath, which was attached to continuous heparinized saline\n flush. A soft Omni catheter was advanced into the aorta and then used to\n select the right common and then external iliac artery with the aid of the\n guidewire. Right lower extremity arteriography with imaging focused on the\n region of the knee was then performed. The area imaged included approximately\n the distal half of the femur and the proximal half of the tibia. Arteriography\n was performed in the frontal and lateral projections. Arteriography of the\n right lower extremity identified patency of the distal right superficial\n femoral artery, popliteal artery, and proximal aspects of the anterior tibial,\n tibioperoneal trunk, posterior tibial and peroneal arteries. Numerous well-\n developed genicular collateral arteries are identified. No pseudoaneurysm or\n active extravasation of contrast was identified. No other evidence of\n arterial bleeding source was identified on the right. A right popliteal\n venogram was attempted via injection of arterial contrast and imaging late in\n to the venous phase; however, the images were nondiagnostic. The Omniflush\n catheter was then withdrawn and arteriography of the left lower extremity\n (Over)\n\n 1:19 PM\n -LAT FEMORAL Clip # \n Reason: ? bleeding\n Contrast: OPTIRAY Amt: 135\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n focused on the area of the knee was then performed by injection through the in\n situ vascular sheath. Imaging was performed in the frontal and lateral\n projections and was focused on the area of the knee. Imaging covered\n approximately the distal half of the femur and proximal half of the tibia. The\n arteriogram demonstrated patency of the distal superficial femoral artery,\n popliteal artery, proximal aspect of the anterior tibial artery, tibioperoneal\n trunk, and proximal aspects of the peroneal and posterior tibial arteries.\n Please note that there is a low bifurcation of the tibioperoneal trunk near\n the junction of the proximal and middle thirds of the tibia. Numerous well-\n developed genicular and muscular collateral arteries are seen around the knee.\n There was somewhat slow flow in the runoff vessels on the left compared with\n the right. This is nonspecific. No arterial source of bleeding identified on\n the left.\n\n The vascular sheath was sutured in place with a single 0 Prolene suture and a\n sterile transparent dressing was applied. The vascular sheath was\n disconnected from the continuous heparinized saline flush and was attached to\n a pressure transduction as it was when the patient presented to the\n angiography suite. The patient received one unit of fresh frozen plasma\n during the procedure. Local anesthesia with 4 cc of 1% lidocaine in the left\n inguinal region subcutaneously. A total of 135 cc of Optiray 320 radiographic\n contrast was utilized. There were no immediate complications.\n\n IMPRESSION: No active extravasation, pseudoaneurysm or other evidence for\n arterial bleeding was identified from the arteries around the knees on either\n side.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-06 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 888880, "text": " 9:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for retroperitoneal bleed, hematoma. esp at groin site\n Field of view: 49.3\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p b/t total knee replacements and groin lines now with\n slowly decreasing Hct.\n REASON FOR THIS EXAMINATION:\n eval for retroperitoneal bleed, hematoma. esp at groin sites.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post bilateral total knee replacement with slowly\n decreasing hematocrit. Please evaluate for retroperitoneal bleed.\n\n TECHNIQUE: Multidetector CT images were obtained from the lung bases to the\n proximal femurs without oral or intravenous contrast.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There are moderate-sized bilateral\n pleural effusions. The lung bases show compressive atelectasis. The\n visualized heart and pericardium are unremarkable. The non-contrast enhanced\n liver, gallbladder, pancreas, spleen, adrenal glands, and non-contrast\n enhanced kidneys are unremarkable. The aorta is normal in caliber and\n contains mild atherosclerotic calcifications. The stomach and intra-abdominal\n loops of small and large bowel are unremarkable. There is no evidence of\n intraperitoneal or retroperitoneal hemorrhage. There is no mesenteric or\n retroperitoneal lymphadenopathy. There is no free air or free fluid.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The rectum, sigmoid colon, intrapelvic\n loops of small and large bowel, uterus, adnexa, and distal ureters are\n unremarkable. The bladder contains a Foley catheter. There is no free air or\n free fluid. Again, there is no evidence of retroperitoneal hematoma. There\n is mild stranding overlying the left common femoral artery and vein. There\n are no focal fluid collections to suggest a hematoma. The right groin is\n unremarkable. There is no pathologically enlarged pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. No evidence for retroperitoneal or intra-abdominal hemorrhage to explain\n the patient's dropping hematocrit.\n\n 2. Mild inflammatory stranding within the left groin likely secondary to\n recent vascular access device in this region. No frank fluid collection is\n identified.\n\n 3. Bilateral pleural effusions with bibasilar compressive atelectasis.\n\n (Over)\n\n 9:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for retroperitoneal bleed, hematoma. esp at groin site\n Field of view: 49.3\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2115-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888474, "text": " 12:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for chf.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p knee surgery with blood loss and hypotension. ET tube\n was advanced 2 cm.\n REASON FOR THIS EXAMINATION:\n Please evaluate for chf and for tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Endotracheal tube advancement.\n\n An endotracheal tube has been advanced in the interval, now terminating\n approximately 2.5 cm above the carina with the neck in a flexed position.\n Cardiac and mediastinal contours are stable. There is an area of worsening\n opacity at the left lung base, likely due to a combination of atelectasis and\n effusion. Minimal patchy opacity has also developed at the right lung base.\n Although these bibasilar opacities are most suggestive of atelectasis, an\n aspiration event should be considered in the appropriate clinical setting.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-11 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 889465, "text": " 9:58 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess swallowing function\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with dysphagia\n REASON FOR THIS EXAMINATION:\n assess swallowing function\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 70-year-old woman with dysphagia.\n\n VIDEO FLUOROSCOPIC SWALLOW:\n\n Fluoroscopic imaging was provided for the speech pathologist. The patient was\n given multiple consistencies of the volume including thick and thin. Note is\n made of poor tongue movement in the oral phase. Discoordinated pharyngeal\n phase is seen. The patient aspirated nectar/thick barium and thin barium with\n ineffective cough.\n\n Further details can be obtained in the online medical record by the speech\n pathologist note.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-09 00:00:00.000", "description": "INTERUP IVC", "row_id": 889210, "text": " 3:27 PM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement.\n Contrast: OMNIPAQUE Amt: 55\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * C1880 VENA CAVA FILTER NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p bilat TKA, w/ DVT, not able to be anti-coagulated\n REASON FOR THIS EXAMINATION:\n IVC filter placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 70-year-old woman status post bilateral total knee\n replacement, with popliteal deep venous thrombosis, not able to be\n anticoagulated, needs IVC filter placement.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. \n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: After the risks and benefits were explained to the\n patient, written informed consent was obtained. The patient was placed supine\n on the angiographic table. The right groin was prepped and draped in the\n standard sterile fashion. A preprocedure timeout was performed to confirm the\n patient's name, procedure and the site. Using ultrasonographic guidance, the\n right common femoral vein was accessed by a 19-gauge needle. A Bentson\n guidewire was then placed through the needle into the inferior vena cava under\n fluoroscopic guidance. The needle was then exchanged for a inner dilator of a\n 4- French sheath. Contrast was injected through the innor dilator and venogram\n was performed, which demonstrated the location of the lowest renal vein (right\n renal vein) at the level of mid L2 vertebral body. An Amplatz wire was then\n placed through the innor dilator into the inferior vena cava. The sheath was\n exchanged for a long sheath of Recovery filter system over the wire and a\n recovery filter was then deployed with its apex just below the lowest renal\n vein. Post-deployment venogram was performed to confirm the location of the\n filter. The sheath was then removed and hemostasis was achieved by direct\n manual pressure for 10 minutes.\n\n COMPLICATIONS: The patient tolerated the procedure well and there were no\n immediate complications.\n\n MEDICATIONS: A total of 50 mcg of fentanyl was given in divided doses during\n the procedure for conscious sedation purposes while continuously monitoring\n the patient's hemodynamic parameters. About 55 cc of Optiray 320 contrast was\n used. Less than 10 cc of 1% lidocaine was applied for local anesthesia.\n\n IMPRESSION: Successful placement of a retrievable filter in the inferior vena\n cava, just below the lowest renal vein (right renal vein).\n (Over)\n\n 3:27 PM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement.\n Contrast: OMNIPAQUE Amt: 55\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2115-12-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 889211, "text": " 3:33 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna/effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p B TKR w/ unstable blood volume and temps\n\n REASON FOR THIS EXAMINATION:\n ? pna/effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Fever. Unstable blood volume.\n\n A right internal jugular vascular catheter remains in place, terminating in\n the lower superior vena cava. The cardiac silhouette is mildly enlarged but\n stable. There is slight upper zone vascular redistribution and minimal\n perihilar haziness. Small pleural effusions are seen on the lateral view.\n\n IMPRESSION: Findings suggestive of mild fluid overload. No definite\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-09 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 889205, "text": " 3:00 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: CT abdomen/pelvis. ? retroperit bleed.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with with decreaseing hct.\n REASON FOR THIS EXAMINATION:\n CT abdomen/pelvis. ? retroperit bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post bilateral knee replacements, persistent dropping\n hematocrits.\n\n COMPARISON: CT.\n\n TECHNIQUE: Axial images through the abdomen and pelvis without oral and IV\n contrast. Multiplanar reformatted images were obtained.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: Again seen are small bilateral pleural\n effusions. There is minimal bibasilar atelectasis. On this unenhanced scan,\n the liver, gallbladder, spleen, pancreas, adrenal glands, kidneys, and ureters\n appear unremarkable. The unopacified loops of large and small bowel are\n unremarkable. The aorta contains minimal atherosclerotic calcifications.\n There is no free air or free fluid in the abdomen. There are no noted\n pathologically enlarged mesenteric or retroperitoneal lymph nodes. There is\n no retroperitoneal hematoma.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is no free fluid. The uterus and\n adnexa appear normal. The bladder contains a Foley catheter and is otherwise\n unremarkable. The rectum and sigmoid colon are normal. There are no\n pathologically enlarged lymph nodes. The pelvic vessels cannot be evaluated\n due to lack of IV contrast.\n\n Within the musculature of both thighs, particularly the quadriceps, there is\n evidence of bilateral hematoma, with expansion of the musculature as well as\n high- and low-attenuation collections. There are hematocrit levels within\n both thighs. The hematoma on the left is greater than right, and extends to\n the height of the quadriceps musculature, and measures approximately 4.5 x 7\n cm.\n\n IMPRESSION: Bilateral thigh hematomas. These findings were discussed with\n the covering orthopedic surgery resident at 5 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2115-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888865, "text": " 3:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p knee surgery with blood loss and hypotension. new\n bandemia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:02 P.M. ON \n\n HISTORY: Knee surgery and blood loss. New leukocytosis. Evaluate possible\n pneumonia.\n\n IMPRESSION: AP chest compared to and 10.\n\n Pulmonary edema has cleared and mediastinal vasculature is no longer as\n engorged. The heart is normal size. Bibasilar atelectasis is improving.\n Upper lungs are clear. Small bilateral pleural effusions are present but\n unchanged. Tip of the right jugular line projects over the superior\n cavoatrial junction. No pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-12-11 00:00:00.000", "description": "Report", "row_id": 1298650, "text": "MICU NPN:\nNEURO: Daughter or husband at bedside at all times and state pt. is confused and \"wants to get up.\" Pt. noted to be pulling at monitoring equip. and C.L. at times and bilat. soft wrist restraints placed per request of family. While restrained, pt. was able to untie one restraint and pulled out central line. IV nurse to attempt IV but pt. very difficult access. If not successful, central line to be placed in am by team.\nCV: Low grade temp. HR 90s-100s SR/ST, no ectopy noted. BP stable. Skin warm and dry with dopplerable pedal pulses bilaterally. Generalized + edema. HCT stable. Repleted with Ca gluc. 2G overnight. Written for IV KCL but never received due to self-d/c of central line.\nRESP: On RA with O2 Sat >92%. LS clear and diminished at bases. Intermittent cough.\nGI/GU: Abd. softly distended with positive bowel sounds. Small BM. Adding thick it to liquids and giving pills crushed with custard. Foley with clear yellow urine >30cc/hr.\nSKIN: Bilateral knee incision sites with staples, C/D/I- small amts of serousang. drainage on dressings- to be changed by ortho this am. Blisters to legs treated with silvadine cream and covered with tegaderm or dsd. Knee immobilizer on RLE and CPM machine on/off LLE q3hrs.\nOTHER: Daughter translating for pt. and very helpful with pt's care. Husband slept overnight in pt's room and speaks a little english. Continue to monitor HCT and assess for further signs of bleeding.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-11 00:00:00.000", "description": "Report", "row_id": 1298651, "text": "pmicu nursing progress note\ncardiac: bp 142-160/64-70 with a pulse of 94-103 sr/st, no ectopy noted. K+ this morning was 4.1. thrombus in right lower extremity---leg/foot more swollen then the left leg. pitting pedal edema in right foot. goal today is neg 1 liter. good dopplerable pedal pulses.\n\nresp: pt is on room air, with o2 sats of 94-98% and resp rate of 20-24. lung sounds are clear, slightly deminished in left lower base.\n\nid: temps of 97.9 ax, 98.8 ax, and 99.4 po. wbc was 10.3. cefazolin was dc'd today.\n\ngi: abdomin soft, with + bowel sounds. down to radiology for video swallow study---pt found to be aspirating. it is felt that pt needs to be eating pureed foods, as well as thickening liquids. for every 120cc of liquid there should be 1 pkt of thickener added. also Honey juices and NOT nectar(can use nectar if thickener added). pt can also take a whole pill when placed in custard or pudding. elevated lfts.\n\ngu: foley in place. bun 20 and creat .6. urine ourput approx 45-50cc/hr. urine is amber in color.\n\nheme: at 6a hct was 31.8 and plts were 208. and at 1P hct was 32.1 and plts were 235.\n\nendo: fingerstick at 12p was 140 and at 6p 167, for which pt received 2u insulin.\n\nneuro: receiving percocet approx q 4-6 hrs. last percocet at 3p. daughter at pt's bedside and translating for nurse and pt. daughter states that pt intermittently becomes confused, but at other times pt is alert/oriented. husband appears to stay the night in pt's room on a cot. pt has is on dilantin for seizure disorder----no seizures noted.\n\nskin: bilateral knee surgery. ortho doctor was asked if he was going to change the dressings on the knees and he stated it was okay for the nurse to do this. so dsgs on both the right and left legs were changed. on both legs the staples are still in place, although there were small intact blisters noted on right leg's incision between the staples and a small amt of serosang drainage. the incision on the left leg has no drainage. xeroform was placed, as this had been removed, then incision covered with abd pad, kerlex and ace bandages. the right knee appeared much more swollen then the left knee.physical therapy by and worked with pt for approx 1 hour. also pt on cpm machine a couple of times today, in between being off the florr for procedures. the inital leg flexion was 60 and increased to 75.\n\naccess: the small #22 angio placed this am has been dc'd, as well as a #20g that was placed in right antecubital for cta. this 320g iv flushed fine, but when at cta unable to flush and another iv needed to be placed. iv nurse unable to place another iv and the radiologist, dr., placed a #20g iv in left foot--suggestion was strongly made by nurse nurse against foot. micu team notified of iv in foot.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-12-11 00:00:00.000", "description": "Report", "row_id": 1298652, "text": "addendum to above note\nskin: on the right leg when the dsg were removed, the area above the knee, along the incision line, is reddened and inflamed.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-11 00:00:00.000", "description": "Report", "row_id": 1298653, "text": "addendum to above notes\npt over to the building for a cta this afternoon of both legs\n" }, { "category": "Nursing/other", "chartdate": "2115-12-12 00:00:00.000", "description": "Report", "row_id": 1298654, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: s/p bilat knee surgery, with complications of blood loss requiring multiple blood transfusions;\n IVC filter Rt leg d/t thrombus;\n was dc'd to floor care, returned to ICU d/t dropped hct level again;\n\nover the night has had very stable hct; vss;\npt using CPM machine to left knee; not using CPM for rt knee d/t rt leg DVT;\n knee dressings changed yesterday, d/i overnight, ACE wrap on left did come abit loose overnight;\n\nfamily present to help with translation of pt needs;\n\npt receiving 2 PO Percocet regularly for pain, with occasional 2 mg IV slow push for breakthrough;\n\nno stool this night;\npt had swallow study done yesterday, requires 1 packet \"thickit\" per 120 cc's fluid;\n\nPLAN:\n1) Plan was for pt to return to floor when hct stable\n2) Phys Therapy to work with pt\n3) monitor coagulapathy\n4) pt w/ hx pulling out lines, provide for pt safety\n5) access an issue for this pt; plan is for pt to receive midline cath today\n6) CPM per phys therapy/ortho\n7) thickit for liquids as stated above\n" }, { "category": "Nursing/other", "chartdate": "2115-12-12 00:00:00.000", "description": "Report", "row_id": 1298655, "text": "MICU NURSING PROGRESS NOTE. 0700-1900.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n PLEASE SEE TRANSFER NOTE FOR SUBJECTIVE DATA. PT OOB FOR 6 HOURS TODAY. MEDICATED FOR PAIN WITH PERCOCET AT 1800. TAKING P.O'S AND PILLS WELL.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-07 00:00:00.000", "description": "Report", "row_id": 1298648, "text": "M/SICU NPN FOR 7A-5P: FULL CODE\n\nPLEASE SEE TRANSFER NOTE FOR MY UPDATED NOTE. PT. BECAME AGITATED AT 1530 FOR APPARENT REASON. HUSBAND AND DAUGHTER CALLED IN AN ATTEMPT TO CALM PT. INTERN IN TO SEE PT., GIVEN A TOTAL OF 2MG HALDOL IVPUSH W/ GOOD EFFECT. ORTHO MD HERE TO WRITE TRANSFER ORDERS. WILL BE TRANSFERRING PT. ON TELEMENTRY TO .\n" }, { "category": "Nursing/other", "chartdate": "2115-12-10 00:00:00.000", "description": "Report", "row_id": 1298649, "text": "Nursing Transfer Acceptance Note 1030am - 1900\n70 yo woman s/p bilat knee replacements readmitted to s/micu from 12 with persistant low HCT despite several transfusions. Last HCT 24.9, INR corrected to now 1.3. Was on lovenox SC for (R) LE thrombus and HCT dropped to 18 on . CT revealed (B)thigh hematomas. IVC filter placed .\nPt arrived in NAD 1030 this morning, pt is Mandarin speaking, daughter or husband at bedside to assist w/communication. Dtr reports that pt is @times confused, thinks that she is in . Pt w/PMH of herpes encephalopathy.\npulmonary HTN\ngout\n?valve disease\nCV: Placed on monitor, ST 102, b/p 158/86. LE's extremely edematous. Dressings intact, reported to be changed by ortho service QD. Peripheral pulses marked and by doppler only. SKIN: rx on \n(L) leg mid thigh lateral aspect 1X2 cm hemoragic blister covered w/tegaderm.\n(R) upper chest 1x1cm skin tear covered w/tegaderm\n(R) upper leg lposterior long skin tear 20cmx1cm covered w/thin duoderm\n(R) lower leg anterior 4x4cm ruptured hemorragic blister covered w/tegaderm.\nCPM machine transfered w/patient however, rx deferred from (r)leg at moment d/t DVT.\nResp: RA O2 sats when pleth good 97%, RR 20, regular. LS: deminished w/poor insp effort, o/w CTA.\nGI: ABD soft, BS+. ASks to be put on bedpan to move bowels, c/o constipation, med w/10mg bisocodyl PR @ 1530, Large OB- formed BM. Appears to tolerate full liquid diet w/thick-it. Will advance to heart health as was tolerating this on floor. Plan is for pt to have video swallow when stable.\nGU: foley patent. Rec'd lasix prior to transfer to floor w/good effect.\nHeme: Transfusing w/1UPRBC, will check Hct once done and plan for HCT later tonight.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-06 00:00:00.000", "description": "Report", "row_id": 1298646, "text": "NPN 0700-1900:\nNeuro: pt is alert, oriented x3, she speaks Mandarin (chinese), the daughter has been in for translation, the pt knows little English. Pt c/o pain at incisional sites, Morphine 4 mg Q 4 hrs standing order, no PRN analgesic was needed.\n\nResp: breathing regularly on room air RR 10-22, SPO2 95-100 %, coughing and expectorating moderate thick yellowish sputum, LS clear.\n\nCV: SR-ST with frequent PVCs HR 88-102, BP 130-162/55-69, transfused with one unit of bld, has Rt IJ line, pulses weak to palpate.\n\nGI/GU: abdomen soft distended, BS present, tolerating PO fluids well, with Foley U/O 70-120.\n\nInt: Dressing over leg dry and clean, physiotherapy done and sat at side of bed, CPM machine alternatingly placed on each leg for about 2 hrs, T max 98.5 bld and urine cx taken, EKG also taken for irregular cardiac rythm. Pt is called out to the regular floor.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-07 00:00:00.000", "description": "Report", "row_id": 1298647, "text": "Nursing Progress note 1900-0700\nReview of Systems:\n\nNeuro: Pt restless but cooperative most of noc, sleeping ~ 30mins in total. Pt found bouncing legs, and finally able to explain to nurse that she thought it was good to move them. Pt also found leaning over side rail, asking to call dgtr @ 0500. Generally able to reorient pt, and pt observed frequently. Pt cont to receive scheduled doses of MSO4 4mg Q4hrs, and also rec'd MSO4 2mg X 1 for C/O discomfort @ 0145.\n\nResp: Pt sating 95-99% on RA with RR 14-21 and regular. Lung snds clear/coarse, diminished @ bases. Pt expectorating mod amts thick white secretions.\n\nCV: HR 93-113SR with occas PVC's. BP 127/77-150/75. Lytes repleted overnight, and am labs include K+ 3.8, Ca 7.5, Phos 2.5. Hct @ 1730 28.3(30.7), and 25.3 @ MN. Pt transfused 1unit PRBC's. Hct immediately after transfucion 26.5. Pt had abd/pelvic CT scan done for ? bld, and scan has not been officially read at this time.\n\nGI: Pt taking clear liqs and swallowing pills well. Abd remains soft and obese/distended with + bowel snds. No BM this shift. Rectal exam guaiac neg.\n\nGU: Urine amber/clear, draining via foley @ 10-75ml/hr. 24hr fluid balance @ MN -284ml, and MN->0600 +565ml. LOS balance +10.5liters. Peripheral edema pronounced.\n\nSkin: Blister on R shin opened, draining large amt serosang fluid. DSD in place. Blister on L outer thigh intact. Dsgs changed on both knees @ 0630. Both knees with staple ligns D&I, small amt serosang drainage on dsg. Xerflo dsgs covered by DSD, covered by Kerlex and elastoplast dsgs. Pt to have pneumo boot on L leg only. CPM rotated with knee immobilizer btwn her knees.\n\nID: Tmax 98.6ax. AM WBC 9.0.\n\nPlan: Called out to floor. Cont to prep for rehab, with PT working with pt. Cont to encourage C&DB. Advance diet as tol per team.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-05 00:00:00.000", "description": "Report", "row_id": 1298644, "text": "Addendum\n\nPt's angiogram was negative but she does have a right popliteal artery clot. Pt is to be started on lovenox and has been restarted on CPM machine beginning with left leg at 1730. Team would like to alternate the legs q 2 hours.\n\nPt also extubated at 1815. Propofol off and pt is tolerating extubation well - on 50% face tent.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-06 00:00:00.000", "description": "Report", "row_id": 1298645, "text": "NURSING PROGRESS NOTE 1900-0700\nReview of Systems:\n\nNeuro: Pt rec'd MSO4 4mg Q 4hrs per standing order, as well as additional MSO4 2mg X 1 @ MN after pt grimacing. Pt intermit agitated, taking off face tent and gown. She was unable to cooperate with taking po meds, and had difficulty swallowing sips H2O. She was freq reoriented with ? success, and slept total of 1-2hrs overnight.\n\nResp: pt on humidified FT @ 50%, with O2 sat 100%. O2 eventually changed to NC 2l with O2 sat remaining 100%, RR 13-19 and regular. Pt expectorated mod amt yellow, thick secretions X 1. Lung snds clear, diminished @ R base.\n\nCV: HR 114->94SR with occas PVC's. Pt rec'd Lopressor 5mg X 2 IVP, as she was unable to swallow po meds ordered. BP 131/56-143/65. AM labs included K+3.7, Ca 7.0, both of which have been repleted. Pt cont to have 3+periph edema, with pedal pulses 2+/Dop bilat. CPM and knee immobilizer changed Q2hrs. Knee dsgs D&I. Hct 30.9, pt transfused 1uPRBC's and post Hct 30. Repeat Hct @ 0530 29.3. Coumadin held as pt NPO, pt rec'd first dose Lovenox @ 2045.\n\nGI: Pt has remained NPO with ? ability to swallow post extubation @ 1815 last pm. Abd obese/soft distended with + bowel snds. No BM, and dgtr reports pt is chronically constipated.\n\nGU: Urine yellow/clear, draining via foley @ 50-110ml/hr. 24hr fluid balance @ MN -733ml, and MN->0600 -120ml. LOS balance +10liters.\n\nID: Tmax 99.7ax, now afebrile. Art line D/C'd and cath tip sent for cx.\n\nPlan: Repeat Hct @ 0830. Ortho team to change knee dsgs.\ncont to rotate CPM/knee immobilizer Q2hrs. Encourage C&DB. Pt to be evaluated for rehab today.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-05 00:00:00.000", "description": "Report", "row_id": 1298642, "text": "S/MICU Nursing Progress Note\n Pt is a 71y/o woman admitted for bilateral knee replacement, during procedure pt bled requiring 7500cc of fluid and 2units of RBC's admitted to MICU as unable to extubate due to edema. POD # 2 cont to drop her hct ..requiring RBC transfusions.\n Respiratory: remains intubated on PSV 5cm PEEP of 5cm did change to MMV mode last night as with sedation of propofol would drop her rate to 7, and min vent to 3liters. BS CTA, secretions minimal. Placed on propofol last night as pt agitated,pulling at tubes and lines.\n Cardiac: HR 80-90's NSR, occasionally dropping her BP to 80's after starting propofol however tx with 250cc fluid bolus with good response. stable to 120-130/70 most of the night. cont to auto diuresis averaging output 50-90cc/hr.\n Heme: still dropping hct to 26.9. after a unit of RBC's recieved 2units of RBC's both hemavac out of knees. no change in drainage on ace on the left knee. Was ordered for coumadin however unable to pass a ngt ... Dr aware.\n Neuro: alert, pulling at lines and ETT, placed on propofol as pt has lanuagage barrier and short term memory deficits. great upper arm strenght.\n Pain: on propofol however still will grimace with turning unable to express needs. cont on Morphine sulfate 2mg q2-3hr.\n Plan: ? need to evaluate bleeding possible angiogram today. wean sedation when ready to extubate. cont with pain meds RTC\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-12-05 00:00:00.000", "description": "Report", "row_id": 1298643, "text": "Nsg Progress Note 0700-1900\n\nCV - Pt has been stable hemodynamically. Afebrile. BP drops only after bolus of propofol for agitation - but she returns to normal within minutes. HR stable - occasional PVC. Ca and KPhos given today.\n\nResp - BS course upper and diminished lower. Suctioned q 2-3 hours for sm-mod amt thin creamy secretions. Pt has been on CPAP 5/5 all day at 40% and tolerated it very well. Pt does have a leak when ETT balloon deflated. If pt does not need to return to OR she will be able to be extubated.\n\nGI - Abd soft - BS present. No NGT.\n\nGU - Foley cath draining adequate amt cl yellow urine.\n\nOrtho - Bilat leg dsgs intact with no signs of bleeding. Hct stable. Pt did go to L2 for angiogram which was negative. Pedal pulses dopplerable. Pt c/o significant amt pain - started on 4mg MSO4 IV q 4hours around the clock and can add more PRN if needed.\n\nNeuro - When pt allowed to lighten - she responds very appropriately to daughter. She calms down after pain med given but becomes very agitated prior to pain med being given.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2115-12-04 00:00:00.000", "description": "Report", "row_id": 1298639, "text": "micu npn 0700-1900\nplease see carevue flowsheet for all objective data\n\nfem tlc resited to rij this afternoon, awaiting cxr confirmation at this point before removal of groain tlc and a line later as well. will attempt now to wake up, put back on and hopefully extubate...\n\nneuro- pt on propofol gtt this am, started on morphine ivp for pain. per conversations w/pt's dtr, she does not feel pt would be a good candidate for pca type of set-up, e.g. knowing to push button each time, etc. pt follows commands w/dtr to interpret. mae.\n\ncv- hr80-90's sinus bp stable most of day, sl hypotensive this afternoon w/propofol bolus for line placement. received 500ns bolus w/good effect.\n\ns/p ortho surgery pt was deferred today per ortho surgery resident d/t pt's bilat groin lines and ?able art bleeding cause of drop oin hct this am,.. to reeval and PT will be back tomorrow am. transfused 2 units this am, hct up to 28.7 from 22.8. no s+s of bleeding. l hemovac came disconnected this am, causing the ace to be blood soaked, has been stable since this am w/no increase in drainage. pt to receive dose of coumadin this pm per primary team..\n\nresp- pt on ps 5/5 most of day until her mv fell w/propofol for line pl, briefly on a/c, now back on , and hopefull to extubate. l/s clear. sm amts of yellow secretions suctioned this pm.\n\ngi/gu- no gi access. no bm today. uop 70-100cc/hr, remains overall quite positive and edematous however..\n\nid- cefazolin x3 doses ordered this am by ortho team. low grade temps..\n\nendo- bs covered w/ss insulin.\n\nsocial- pt's daughter and pt's husband in this am. daughter is english speaking. all aware of plan of care for the day and will be back at some point this pm.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-04 00:00:00.000", "description": "Report", "row_id": 1298640, "text": "Resp Care\n\nPt remains intubated and on CPAP/PSV. Was place on A/C for a short time for a line placement. PLan is to still extubate was sedation clears. ABG's stable on wutg adequate MV and rr. Bs are clear and suctioning small thick yellow\n" }, { "category": "Nursing/other", "chartdate": "2115-12-05 00:00:00.000", "description": "Report", "row_id": 1298641, "text": "Respiratory Care Note:\n patient remains intubated and on ventilatory support. Alarms are functioning properly and wnl. BS clear. SX'd for a scant/small amount of yellow secretions. Vent settings changed to MMV due to periods of apnea last evening. RSBI this am is 36.8. Plan is to continue monitoring closely and wean when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-03 00:00:00.000", "description": "Report", "row_id": 1298634, "text": "Resp. Care Note\nPt transported for PACU to ICU for further management following bilat knee replacements. See flowsheet for current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-03 00:00:00.000", "description": "Report", "row_id": 1298635, "text": "MICU NURSING ADMISSION NOTE. 1800-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Admitted to Micu east from pacu s/p bilat total knee replacement. Pt had large ebl of cc in o.r. and was fluid resc. with 8250 colloids, incl. 2 units of prbc's. Also had 600cc urine out. Medicated in o.r. with multiple pain medications, propofol, neo gtt and lopressor. Pt was hypotensive and peripheral access and A line was lost reportedly d/t fast increase in gen. edema. In pacu unable to obtain nbp bilat. Also diff. to obtain access. Finaly able to obtain groin multilumen and then femoral A line. Transfused with 2 units of prbc's and started on neo gtt at 2-3 mcg. Found that pt was losing large amt of blood through bilat. knee's with rt> lt. Rt leg also became very edemetous and hard with cool foot. Pulses were obtained by doppler. Dr. was asked to come and see pt, rt leg rewrapped in compression ace and placed in brace. Bilat hemavac's drained 375 from rt knee and 120 from lt knee.\n\n Upon arrival to unit pt was awake and appeared alert. She is manderin speaking with minor understanding of english. Moving all extrem. and is restrained for safety. Sedated on 30 mcg/kg/min of propofol. Remains intubated, lung sounds are clear bilat. Ventilator settings simv .50/600/12/5/5. O2 saturation on present settings 97-100%. Abg sent. Sinus rhythm with no ectopy noted, rate 70's. Abp 110's to 120's systolic. Rt femoral multilumen in place. Lt femoral A line sharp, site wnl. Remains on neo at .74 mcg/kg/min. Bilat pp by doppler. Labs drawn in pacu pending. Generalized 3+ edema. Cxr completed in pacu.\n\n Bilat knee x-rays pending. Surgical resident will be up to remove drain from rt knee this pm. Request removal off brace when knee x-ray done. Was given kefzol 1 gm iv preop at 1200.\n\n Plan is to monitor hct and lower extrem. pulses and output. keep sedated and wean pressor as tolerated. Elevate lt wrist for edema r/t jade bracelet.\n Note Written by RN stored by Rn\n" }, { "category": "Nursing/other", "chartdate": "2115-12-04 00:00:00.000", "description": "Report", "row_id": 1298636, "text": "Respiratory Care\nRemained intubated and ventilated on simv with no remarkable changes overnight. Pt was well sedated and breathing in synch with the vent.ABGS last evening were within normal limits, good oxygenation. RSBI = 75. Spontaneous breathing trial started @ 0400,with plan to extubate later this morning.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-04 00:00:00.000", "description": "Report", "row_id": 1298637, "text": "S/MICU Nursing Progress Note\n pt is a 70y/o woman admitted from PACU after bilateral knee replacements. developed bleeding intraoperative requiring 7500cc of IV fluids and 2 units of RBC's. started Neo for low BP. when assessing for possible extubation there was no leak ... left intubated overnight.\n System review:\n Respiratory: on SIMV 12x600cc PEEP 5cm, FIO2 50% ABG showed 233/33/7.35 weaned FIo2 to 40% maintaining O2 sat 98-100%. lungs CTA, placed on Spontaneous breathing trial at 4am, tolerating well. TV 400-600cc with RR 20-25. ABG pnd.\n Cardiac: Hr 70-80's NSR, intitally on Neo at 0.7mcg/kg/min did receive a total of 750cc of LR boluses. then placed on LR at 100cc/hr for 2 liters, able to wean the Neo to off by 1am. BP range 110-130/60-70's still very edematous. (of note it is documented in chart pt +3 edema of extremites before surgery)\n GU: foley in place, uo only averaging 10-20cc/hr. I&O's show LOS +8500cc.\n GI: abd soft, hypoactive BS, no stool.\n Neuro: sedated on propofol all night at 30mcg/kg/min weaned to 24mcg/kg/min this morning. not responding to commands but is moving head and arms purposefully.,\n Ortho: both legs wrapped in ace bandages, pulses dopplerand increasing in strength overnight. intitally toes cool to touch, warming up as pt is off pressors and systemic temp up to 97 ax. warming blanket on for 3hours. hemavacs each knee. left draining more than the right. hct at 12midnight down to 29.3, ( had been 32 at ). given cryoprecipate(fibrinogen at 97) and pbag of platelets.(plt ct 85) am labs pnd.\n Endo: follow SS insulin orders. FS at 12 192 did receive 2uints of insulin.\n Plan: spont breathing trial, check for leak, possible extubation this morning. follow I&O's closely. physical therapy consult this am.\n\n" }, { "category": "Nursing/other", "chartdate": "2115-12-04 00:00:00.000", "description": "Report", "row_id": 1298638, "text": "micu npn 0700-1900\npt remains on , same mv, however, not as awake as earlier in day.. has not recevied pain meds since ~1300. rr dropping to w/vols over a liter now..? still debate on whether or not to wait til tomorrow am for extubation. r ij tlc confirmed by cxr. r fem line pulled. aline remains in l groin, to be pulled before extubation.. cont to assess.\n" } ]

[ { "category": "Radiology", "chartdate": "2168-11-24 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1221711, "text": "GALLBLADDER SCAN Clip # \n Reason: DUCT STUMP LEAK CONCERN FOR PERSISTENT BILE LEAK\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 3.9 mCi Tc-m DISIDA ();\n HISTORY: Recent cholecystectomy, now with elevated WBC count.\n\n METHODS: Following the intravenous injection of tracer, serial one-minute images\n of tracer uptake into the hepatobiliary system were obtained for 93 minutes.\n\n INTERPRETATION: Serial images over the abdomen show prompt uptake of tracer into\n the hepatic parenchyma in a homogeneous pattern.\n\n At 6 minutes tracer is noted in the surgical drain, flowing externally. At\n approximately 24 minutes, tracer is seen to accumulate in the gallbladder fossa\n at the site of the drain. At approximately one hour, tracer is seen in the\n small bowel.\n\n IMPRESSION: Active fluid collection in the gallbladder fossa; however, the\n fluid collection appears to be connected to the surgical drain, and is seen to\n flow through the drain.\n\n\n\n\n , M.D. Approved: 3:20 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2168-11-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1221852, "text": " 4:04 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for interval change of pleural effusions and/or pne\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with known pleural effusions and crackles on exam\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change of pleural effusions and/or pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n TECHNIQUE: PA and lateral chest views were reviewed in comparison with prior\n chest radiographs through with the most recent from , .\n\n FINDINGS: Bilateral lung volumes are low. Lungs are now better aerated as\n compared to the prior radiograph from . Pulmonary edema has\n resolved. Bilateral increased lower lung opacities likely from lobar collapse\n and probable right middle lobe collapse is persisting. Associated bilateral\n mild-to-moderate pleural effusions are similar. Mild- to moderate-sized\n hiatal hernia is present. Aorta is remarkable for moderate atherosclerotic\n calcification and mild tortuosity. Heart size is normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1221239, "text": " 1:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p CCY c/b biliary leak\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Biliary leak, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Very lower lung volumes with areas of bilateral basal atelectasis.\n On the current image, presence of minimal left and right pleural effusion\n cannot be excluded. Mild cardiomegaly without evidence of pulmonary edema.\n No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1221363, "text": " 8:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please perform upright AP. Interval change.\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Please perform upright AP. 81 year old man with open chole c/b cystic duct\n leak, now with increased crackles at bases of lung.\n REASON FOR THIS EXAMINATION:\n Please perform upright AP. Interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Open cholecystectomy complicated by cystic duct leak with\n crackles at the lung bases, assess for interval change.\n\n TECHNIQUE: Portable AP upright radiograph of the chest.\n\n COMPARISONS: Chest radiograph of one day prior.\n\n FINDINGS: Left PICC has been removed. The lungs are clear aside from\n bibasilar atelectasis with right greater than left pleural effusions which\n appears more conspicuous on the right though this could be due to positioning.\n Heart size is mildly enlarged with calcification of the aortic knob noted.\n\n Cholecystectomy clips and plastic CBD stent are noted in the upper abdomen but\n incompletely assessed.\n\n IMPRESSION: Right greater than left pleural effusions with associated\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1221487, "text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 81 year old man with bile leak with fluid overload s/p diure\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with bile leak with fluid overload s/p diuresis\n REASON FOR THIS EXAMINATION:\n 81 year old man with bile leak with fluid overload s/p diuresis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bile leak and fluid overload after diuresis.\n\n TECHNIQUE: Upright radiograph of the chest.\n\n COMPARISON: Chest radiograph from one day prior.\n\n FINDINGS: The lungs are again low in volume. Right small-to-moderate pleural\n effusion is unchanged with slight interval decrease in degree of left pleural\n effusion. Tip of right PICC is not well seen but appears to be in the distal\n SVC. The cardiac silhouette is not well evaluated but appears mildly\n enlarged.\n\n IMPRESSION: Bibasilar atelectasis with small-to-moderate right greater than\n left pleural effusions. The left is minimally improved.\n\n" }, { "category": "Radiology", "chartdate": "2168-11-19 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1221175, "text": " 3:09 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Source of infection?\n Admitting Diagnosis: POST-ERCP\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p CCY on for gangrenous gallbladder with JP drain, s/p\n ERCP on now with leukocytosis and concern for sepsis\n REASON FOR THIS EXAMINATION:\n Source of infection?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE EXAMINATION: This is an 80-year-old man that is status post\n cholecystectomy () due to gangrenous gallbladder. The\n cholecystectomy was started as a laparoscopic one and then was diverted into\n an open cholecystectomy. Post-surgical HIDA scan revealed a bile leak and the\n patient underwent ERCP in which sphincterectomy was performed and biliary\n stent was placed. The patient is now with elevated leukocytosis and the\n request is to evaluate for an intra-abdominal source.\n\n COMPARISONS: No priors are available.\n\n TECHNIQUE: Multidetector CT examination with IV contrast administration and\n without oral contrast administration.\n\n Sagittal and coronal reformations were obtained.\n\n Total DLP: 770.33 mGy-cm.\n\n FINDINGS: Coronary calcifications are seen along with calcification in the\n aortic annulus valve.\n\n Bilateral small pleural effusions, right greater than left, with secondary\n atelectasis. Atelectasis is seen in the right lower lobe and in the lingula.\n\n ABDOMEN: - drain is seen in the inferior margin of the surgical\n bed. Unorganized fluid collection with a few air bubbles is seen in the\n surgical bed. Pneumobilia is detected, compatible with the patient's known\n sphincterectomy. The liver is within normal limits. There is no intra- or\n extra-hepatic biliary dilatation. A well located biliary stent is seen. A\n rounded lesion is seen just superior to the entrance of the biliary duct into\n the ampulla of Vater. The lesion has an air-fluid level and measures 25 x 30\n mm (2B,32). The portal vein is patent.\n The spleen, the adrenals and the left kidney are normal. A simple cyst is\n seen in the upper pole of the right kidney measuring 27 x 34 mm (2B,33). A\n smaller cyst is seen in the lower part of the right kidney with fine\n septations that enhance after contrast administration- compatible with simple\n cyst. Both kidneys enhance and secrete adequately. Fat stranding is seen\n between the uncinate process and the border of the second and third part of\n the duodenum along with a few tiny air bubbles (2B,39). A small amount of\n fluid is seen in the anterior pararenal space bilaterally and in the right and\n (Over)\n\n 3:09 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Source of infection?\n Admitting Diagnosis: POST-ERCP\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left gutter, right greater than left. The transverse and the descending colon\n are decompressed with retained oral contrast within them. Diverticula are\n seen along the sigmoid colon.\n\n A small bowel loop is detected herniating into the umbilical laparoscopic\n trocar entrance region (2B,64) with mild dilatation of small bowel loop\n proximal to it. Bilateral inguinal hernias, left greater than right.\n\n Small periportal lymph node is detected, most probably reactive one.\n\n Atherosclerosis is seen throughout the aorta.\n\n Celiac axis origin stenosis is detected (2B,34).\n\n PELVIS: Free fluid is seen within the pelvis. Prostatic calcifications are\n detected.\n\n Foley catheter is seen within the urinary bladder. There is no\n lymphadenopathy in the pelvis.\n\n OSSEOUS STRUCTURES: Compression fracture of L2 vertebra.\n\n IMPRESSION:\n 1. Nonorganized fluid collection within the surgical bed with a few air\n bubbles, most probably post-surgical changes.\n 2. A rounded structure is seen just superior to the insertion of the biliary\n stent, it contains air-fluid level and is compatible with the large\n periampullary diverticulum that was seen on ERCP examination.\n 3. Small bowel loop that herniates into the umbilical laparoscopic trocar\n entrance region is seen with mild proximal dilatation of a small bowel loop,\n follow-up examination with abdominal plain films is recommended in cases of\n suspicious developing small-bowel obstruction.\n\n These findings were discussed by Dr. and Dr. by phone at 5:30\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2168-11-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1221169, "text": " 12:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrates\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with recently diagnosed gangrenous gallbladder s/p JP drain who\n is transferred from OSH for ERCP. He is now s/p ERCP with sphinchteromety with\n post-operative course complicated by hematemesis\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recently diagnosed gangrenous gallbladder. Evaluation for\n pneumonia.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are low. Areas of atelectasis are seen at both\n the left and the right lung base. Borderline size of the cardiac silhouette\n without evidence of pulmonary edema. Normal hilar and mediastinal contours.\n No pneumonia. No pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2168-11-30 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1222382, "text": " 5:27 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evaluate for increased abdominal distention\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man s/p open chole. for gangrenous gallbladder\n REASON FOR THIS EXAMINATION:\n evaluate for increased abdominal distention\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:32 PM\n 1. Essentially unchanged pancreatitis without pseudocyst formation.\n\n 2. No significant fluid within the abdomen.\n\n 3. Appropriately positioned CBD stent.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old man status post open cholecystectomy for gangrenous\n gallbladder. Evaluate for increased abdominal distension.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with oral\n but without IV contrast. Multiplanar reformations were obtained and reviewed.\n DLP: 697.86 mGy-cm.\n\n FINDINGS: The partially imaged lungs show small bilateral non-hemorrhagic\n effusions with associated atelectasis. The partially imaged heart shows\n aortic annular and coronary artery calcifications. The heart is unremarkable.\n There is a trace pericardial effusion.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST:\n\n The liver shows unchanged pneumobilia secondary to a metallic stent which ends\n in the duodenum appropriately. Cholecystectomy clips are noted in appropriate\n position. A small fluid collection in the gallbladder fossa with a tiny\n pocket of air is unchanged compared to the previous examination. A\n - drain exiting out the right lower quadrant is unchanged in\n position compared to the previous examination. The spleen, both adrenals,\n left kidney are unremarkable. Diffuse stranding around the pancreatic tissue\n without discrete fluid collections is consistent with post-ERCP pancreatitis\n as previously noted. A simple cyst is noted in the upper pole of the right\n kidney, unchanged. There is small amount of non-hemorrhagic free fluid within\n the abdomen. No significant free air is noted. The small and large bowel\n loops show minimal dilatation of some small bowel loops in the pelvis likely\n related to ileus. No abdominal, retroperitoneal or mesenteric lymphadenopathy\n by CT size criteria is present.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST:\n\n The rectum, sigmoid colon, bladder, prostate, and seminal vesicles are\n (Over)\n\n 5:27 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evaluate for increased abdominal distention\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable. There is a small amount of non-hemorrhagic pelvic free fluid.\n No pelvic or inguinal lymphadenopathy is present.\n\n OSSEOUS STRUCTURES:\n\n The visible osseous structures show no suspicious lytic or blastic lesions or\n fractures. Compression deformity of the L2 vertebral body is unchanged\n compared to the previous examination.\n\n IMPRESSION:\n\n 1. Essentially unchanged pancreatitis without pseudocyst formation.\n\n 2. No significant fluid within the abdomen.\n\n 3. Appropriately positioned CBD stent.\n\n" }, { "category": "Radiology", "chartdate": "2168-11-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1221284, "text": " 9:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm left picc. tip?\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 44cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n left-sided PICC line. The course of the line is unremarkable, the tip of the\n line projects over the inflow tract of the right atrium. There is no evidence\n of complication, notably no pneumothorax.\n\n Otherwise, the radiograph is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-11-21 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1221322, "text": " 5:30 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: duodenal leak (PO contrast)\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n This is an 80 year old gentleman with DM2, mild dementia with recently\n diagnosed gangrenous gallbladder s/p JP drain who is transferred from OSH for\n ERCP. He is now s/p ERCP with sphinchteromety with post-operative course\n complicated by hematemesis and repeat ERCP with cauterization and epi injection\n of sphincter\n REASON FOR THIS EXAMINATION:\n duodenal leak (PO contrast)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JPld MON 6:49 PM\n Increasing bilateral pleural effusions with associated compressive\n atalectasis. Peripancreatic fluid and standing is stable due to postop\n pancreatitis. Phlegmanous change around the pancreatic head in the surgical\n bed without a discrete collection. No evidence for duodenal leak or bleed.\n Stable 1.8 x 8.2 cm fluid collection inferior to the gastric body measuring 50\n without an enhancing rim. This may represent an evolving phlegmon but not\n drainable at this time.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with history of dementia and diabetes, status\n post gangrenous gallbladder removal with - drain placed at outside\n hospital, status post ERCP with sphincterotomy, complicated by hematemesis and\n repeat ERCP with cauterization and epinephrine injection of sphincter. Rule\n out duodenal leak.\n\n COMPARISON: .\n\n COMPARISON: MDCT images were obtained from the lung bases to the pubic\n symphysis. Oral and 130 mL of Omnipaque IV contrast were administered. Axial\n images were interpreted in conjunction with coronal and sagittal reformats.\n\n DLP: 724 mGy-cm.\n\n FINDINGS:\n\n CT ABDOMEN:\n\n The lung bases demonstrate bilateral effusions with associated compressive\n atelectasis, slightly increased since the prior exam. Calcification of native\n coronary arteries and aortic valve calcifications are unchanged. The distal\n pulmonary artery in the left lower lobe is not well opacified on this CT scan\n which is not protocoled for evaluation of the pulmonary arteries.\n\n Biliary stent is stable in position with unchanged mild pneumobilia, expected\n after sphincterotomy and stent placement. There are no new focal hepatic\n (Over)\n\n 5:30 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: duodenal leak (PO contrast)\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n parenchymal lesions. Superior to the insertion of the biliary stent is a\n collection containing contrast and air, likely representing the duodenal\n diverticulum, previously described on ERCP. The gallbladder is absent with\n surgical clips remaining in the gallbladder fossa. - drain is\n unchanged in position without a fluid collection at its tip. The portal and\n splenic veins are patent and unremarkable. There is unchanged peripancreatic\n edema and stranding, compatible with post-ERCP pancreatitis. Phlegmonous\n change is present around the pancreatic head in the surgical bed without a\n discrete collection. The spleen and adrenal glands are unremarkable. The\n right kidney contains two simple cysts that are unchanged. The left kidney is\n normal. Retroperitoneal lipomatosis is unchanged.\n\n The esophagus and stomach are normal. The small bowel and colon are normal in\n course and caliber without extraluminal contrast to suggest duodenal leak or\n bleed. There is an unchanged 8.2 x 1.8 cm fluid collection inferior to the\n gastric body measuring 50 Hounsfield units, without an enhancing rim, and may\n represent an evolving phlegmon, but is not drainable at this time.\n\n Celiac axis origin stenosis is unchanged. The intraabdominal vasculature is\n otherwise unremarkable. Moderate abdominal aortic calcification is unchanged.\n No retroperitoneal or mesenteric lymphadenopathy. No ascites or\n intraabdominal free air.\n\n CT PELVIS:\n\n The bladder is unremarkable except for a well positioned Foley catheter.\n Dystrophic calcifications are present within the prostate gland. No inguinal\n or pelvic lymphadenopathy. Bilateral inguinal hernias are unchanged. Pelvic\n free fluid persists.\n\n OSSEOUS STRUCTURES: L2 compression fracture is unchanged in appearance.\n There are no new lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. No evidence of duodenal leak.\n\n 2. A collection containing contrast and air, adjacent to the insertion of the\n biliary stent, likely represents the previously described duodenal\n diverticulum.\n\n 3. 8.2 x 1.8 cm fluid collection inferior to the gastric body may represent\n an evolving phlegmon, but is not drainable at this time.\n\n 4. Stable position of biliary stent with mild associated pneumobilia.\n\n (Over)\n\n 5:30 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: duodenal leak (PO contrast)\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Stable position of JP drain.\n\n 6. Unchanged peripancreatic edema and stranding, compatible with post-ERCP\n pancreatitis without necrosis or associated vascular complications.\n\n 7. Unchanged celiac axis origin stenosis.\n\n 8. Left lower pulmonary artery is not definitively seen on this CT scan not\n protocoled to evaluate the pulmonary arteries.\n\n" }, { "category": "Radiology", "chartdate": "2168-11-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1221373, "text": " 10:06 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 48cm right picc. tip?\n Admitting Diagnosis: POST-ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 48cm right picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New PICC, assess for placement.\n\n TECHNIQUE: Portable upright radiograph of the chest.\n\n COMPARISONS: Chest radiograph from one day prior.\n\n FINDINGS: New right PICC terminates in the right atrium and should be\n withdrawn by 3.5 cm for more optimal positioning. Lung volumes are low with\n bilateral right greater than left pleural effusions and resultant atelectasis.\n Mild vascular congestion is also noted. Left PICC has been removed.\n\n IMPRESSION:\n 1. Left PICC 3.5 cm beyond the superior cavoatrial junction. This finding\n was discussed with from IV nursing by Dr. at 1005 hours on\n by phone.\n 2. Persistent low lung volumes with right greater than left pleural effusions\n and atelectasis.\n\n" }, { "category": "Echo", "chartdate": "2168-11-22 00:00:00.000", "description": "Report", "row_id": 93818, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 130\nBSA (m2): 1.56 m2\nBP (mm Hg): 126/72\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:56\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral\nannular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The\nestimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging\nsuggests a normal left ventricular filling pressure (PCWP<12mmHg). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are moderately thickened. There is mild aortic valve stenosis (valve\narea 1.2cm2). Trace aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is mild pulmonary\nartery systolic hypertension. There is an anterior space which most likely\nrepresents a prominent fat pad.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global and\nregional biventricular systolic function. Mild aortic valve stenosis.\nPulmonary artery hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Echo", "chartdate": "2168-11-21 00:00:00.000", "description": "Report", "row_id": 93819, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Left ventricular function. Shortness of breath.\nHeight: (in) 60\nWeight (lb): 130\nBSA (m2): 1.56 m2\nBP (mm Hg): 133/68\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 19:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No valvular AS. The increased transaortic velocity is related to\nhigh cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: No TR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PR.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Echocardiographic\nresults were reviewed with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). The right ventricular\ncavity is dilated with normal free wall contractility. There are three aortic\nvalve leaflets. The aortic valve leaflets are moderately thickened. There is\nno valvular aortic stenosis. The increased transaortic velocity is likely\nrelated to high cardiac output. No aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. The\npulmonary artery systolic pressure could not be determined. There is a very\nsmall pericardial effusion. There are no echocardiographic signs of tamponade.\n\nIMPRESSION: Preserved biventricular systolic function. Dialated right\nventricle. Moderate aortic valve thickening. Very small pericardial effusion\nwith no echocardiographic evidence of tamponade physiology.\n\nDr. was notified in person of the results at the end of the study\n\n\n" }, { "category": "ECG", "chartdate": "2168-11-29 00:00:00.000", "description": "Report", "row_id": 249401, "text": "Sinus rhythm. Poor R wave progression across the precordium. Q waves in\nleads III and small in lead aVF of unknown significance. Compared to the\nprevious tracing the rate is slower. Otherwise, no clincally significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2168-11-22 00:00:00.000", "description": "Report", "row_id": 249402, "text": "Sinus tachycardia. Possible old inferior myocardial infarction. Possible\nold septal myocardial infarction. Diffuse non-specific ST-T wave\nabnormalities. Compared to the previous tracing of criteria for\nseptal myocardial infarction are now seen. ST-T wave abnormalities appear less\nmarked.\n\n" }, { "category": "ECG", "chartdate": "2168-11-20 00:00:00.000", "description": "Report", "row_id": 249403, "text": "Sinus tachycardia. Possible inferior myocardial infarction, age undetermined.\nLate R wave progression. Low precordial voltage. ST-T wave abnormalities.\nSince the previous tracing of ST-T wave abnormalities are more\nprominent. Clinical correlation is suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2168-11-19 00:00:00.000", "description": "Report", "row_id": 249404, "text": "Sinus tachycardia. Consider inferior myocardial infarction with\nnon-diagnostic inferior Q waves and minor ST segment elevation. Possible\nT wave inversion. R wave progression is later. ST-T wave abnormalities are\nmore prominent. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2168-11-18 00:00:00.000", "description": "Report", "row_id": 249405, "text": "Sinus rhythm at upper limits of normal rate. Inferior and lateral precordial\nT wave abnormalities. Since the previous tracing the rate is faster. T wave\nabnormalities are more prominent. There may be slight ST segment elevation and\nT wave inversion, particularly in leads III and aVF, with non-specific change\nin lead II. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2168-11-18 00:00:00.000", "description": "Report", "row_id": 249406, "text": "Sinus rhythm. Borderline P-R interval prolongation. Q wave is variable\nin lead aVF related to beat to beat QRS variation. Low precordial voltage.\nNo previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2140-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455517, "text": "Chief Complaint:\n 24 Hour Events:\n - IABP pulled\n - Extubated\n - Started captopril and uptitrated for afterload reduction\n - Pm Hct stable\n - PM lytes with K 3.6 so repleted then with more lasix for extubation\n had K 3.3 so received more K\n - Temp 100.1 and sputum with 3+ GPCs and strep pneumo from OSH cultures\n so started vanc/zosyn\n - Got 20mg lasix IV X1 prior to extubation for frothy secretions\n although UOP good after the first dose in the am\n - Restarted hep gtt at 4pm for apical AK on TTE (will need transition\n to coumadin prior to discharge)\n - Started coreg as HRs in 90s and BPs 150s/80s\n - Delirious overnight and suspect ICU psychosis. Zyprexa given and did\n not respond so got haldol.\n - Flashed at 2am with BPs 180s/120s, tachypnea to 30s, and HR 120s with\n tiny drop in sats responded to nitro gtt, morphine (2mg), and\n non-invasive mask ventilation. Got 40mg IV lasix with only 20ml out so\n got 80mg as CXR looked like more pulm edema (although poor film) -> put\n out 2L (from AM). EKG with inferior ST depressions and little\n longer QT with continued STE V1-V3 as in prior.\n .\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Nitroglycerin - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 AM\n Heparin Sodium - 11:26 PM\n Haloperidol (Haldol) - 02:00 AM\n Morphine Sulfate - 02:18 AM\n Furosemide (Lasix) - 03:00 AM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 103 (72 - 123) bpm\n BP: 116/66(76) {92/50(67) - 191/125(125)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 89-100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 6 (5 - 304)mmHg\n Total In:\n 1,590 mL\n 597 mL\n PO:\n TF:\n IVF:\n 1,590 mL\n 597 mL\n Blood products:\n Total out:\n 2,997 mL\n 1,093 mL\n Urine:\n 2,997 mL\n 1,093 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,407 mL\n -496 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 512 (512 - 670) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/37/334/25/0\n Ve: 11.8 L/min\n PaO2 / FiO2: 668\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: tr pedal edema\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 408 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.9 %\n 8.1 K/uL\n [image002.jpg]\n 04:26 AM\n 04:44 AM\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n WBC\n 8.7\n 8.1\n Hct\n 33.0\n 31.5\n 32.9\n Plt\n 331\n 408\n Cr\n 0.7\n 0.8\n 0.8\n TCO2\n 23\n 23\n 24\n 19\n 20\n 24\n Glucose\n 83\n 101\n Other labs: PT / PTT / INR:15.6/80.0/1.4, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n -cont captopril and carvedilol for afterload reduction unlikely to\n require dobutamine for afterload reducing as pressures remained stable\n on 1:4\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will needcoumadin prior to d/c for\n apical AK.\n - Check pulses frequently with IABP in place but will be d/c\nd today\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today following IABP removal\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however\n -cont vanc/zosyn for VAP cov\ng until defervesces\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455525, "text": "Chief Complaint:\n 24 Hour Events:\n - IABP pulled\n - Extubated\n - Started captopril and uptitrated for afterload reduction\n - Pm Hct stable\n - PM lytes with K 3.6 so repleted then with more lasix for extubation\n had K 3.3 so received more K\n - Temp 100.1 and sputum with 3+ GPCs and strep pneumo from OSH cultures\n so started vanc/zosyn\n - Got 20mg lasix IV X1 prior to extubation for frothy secretions\n although UOP good after the first dose in the am\n - Restarted hep gtt at 4pm for apical AK on TTE (will need transition\n to coumadin prior to discharge)\n - Started coreg as HRs in 90s and BPs 150s/80s\n - Delirious overnight and suspect ICU psychosis. Zyprexa given and did\n not respond so got haldol.\n - Flashed at 2am with BPs 180s/120s, tachypnea to 30s, and HR 120s with\n tiny drop in sats responded to nitro gtt, morphine (2mg), and\n non-invasive mask ventilation. Got 40mg IV lasix with only 20ml out so\n got 80mg as CXR looked like more pulm edema (although poor film) -> put\n out 2L (from AM). EKG with inferior ST depressions and little\n longer QT with continued STE V1-V3 as in prior.\n .\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Nitroglycerin - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 AM\n Heparin Sodium - 11:26 PM\n Haloperidol (Haldol) - 02:00 AM\n Morphine Sulfate - 02:18 AM\n Furosemide (Lasix) - 03:00 AM\n Other medications: ASA 325, plavix 75, atorvastatin 80, HISS<\n pantoprazole 40, colace, captopril 12.5, carvedilol 3.125mg \n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 103 (72 - 123) bpm\n BP: 116/66(76) {92/50(67) - 191/125(125)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 89-100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 6 (5 - 304)mmHg\n Total In:\n 1,590 mL\n 597 mL\n PO:\n TF:\n IVF:\n 1,590 mL\n 597 mL\n Blood products:\n Total out:\n 2,997 mL\n 1,093 mL\n Urine:\n 2,997 mL\n 1,093 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,407 mL\n -496 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 512 (512 - 670) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/37/334/25/0\n Ve: 11.8 L/min\n PaO2 / FiO2: 668\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: tr pedal edema\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 408 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.9 %\n 8.1 K/uL\n [image002.jpg]\n 04:26 AM\n 04:44 AM\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n WBC\n 8.7\n 8.1\n Hct\n 33.0\n 31.5\n 32.9\n Plt\n 331\n 408\n Cr\n 0.7\n 0.8\n 0.8\n TCO2\n 23\n 23\n 24\n 19\n 20\n 24\n Glucose\n 83\n 101\n Other labs: PT / PTT / INR:15.6/80.0/1.4, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n -cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2\n -cont vanc and zosyn for now\n -f/u OSH culture data, narrow as able\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455691, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n BPs 90-one teens/60-70s, HR 70-80s SR. UOP trending down 15-30cc/hr\n Action:\n 12.5mg Captopril and 3.125 Coreg given as ordered. 80mg IV lasix given\n at 22:00. Heparin gtt for apical AK therapeutic\n Response:\n HD stable, tolerated cardiac meds. Good response to lasix, Diuresed ~2L\n in 4 hrs, uop trending down this AM. Neg 2100 at MN\n Plan:\n Continue cardiac meds, hold per BP parameters\n ? adding standing dose PO lasix, replete lytes as indicated.\n GOAL -1L/day\n Past smoker, quit 6 wks ago\n continue to encourage and\n support smoking cessation\n Viability study prior to Discharge\n Daily Coags, ? start coumadin (AM INR 1.5)\n Pneumonia, other\n Assessment:\n Low grade temp 99.4, WBC flat, productive cough. Sats >95% w/\n supplemental 02 2L. Denies SOB/DOE\n Plan:\n Levofloxacin x4 more days\n Encourage C&DB, wean 02\n ^ activity as tol, get OOB, PT c/s\n Anemia, other\n Assessment:\n No evidence bleeding (liq stool, guiac neg). AM HCT stable at 37.5\n (32.9)\n Plan:\n Continue to monitor s/sx bleeding, goal HCT >30\n Altered mental status (not Delirium)\n Assessment:\n Pleasant and cooperative, A&Ox3. Speaking to relatives on phone.\n Difficult falling asleep. Requested sleep aid\n Action:\n 5mg ambient given. Safety/fall precautions maintained, pt encouraged to\n use call light for assistance prior to getting OOB to commode.\n Response:\n Slept well after\n Plan:\n Continue fall/safety precautions, re-orient PRN\n Provide calm environment, increase stimulation during the\n day to promote rest/sleep at night.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455674, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n BPs 90-one teens/60-70s, HR 70-80s SR. UOP trending down 15-30cc/hr\n Action:\n 12.5mg Captopril and 3.125 Coreg given as ordered. 80mg IV lasix given\n at 22:00. Heparin gtt for apical AK therapeutic\n Response:\n HD stable, tolerated cardiac meds. Good response to lasix, Diuresed ~2L\n in 4 hrs, uop trending down this AM. Neg 2100 at MN\n Plan:\n Continue cardiac meds, hold per BP parameters\n ? adding standing dose PO lasix, replete lytes as indicated.\n GOAL -1L/day\n Past smoker, quit 6 wks ago\n continue to encourage and\n support smoking cessation\n Viability study prior to Discharge\n Daily Coags, ? start coumadin (AM INR 1.5)\n Pneumonia, other\n Assessment:\n Low grade temp 99.4, WBC flat, productive cough. Sats >95% w/\n supplemental 02 2L. Denies SOB/DOE\n Plan:\n Levofloxacin x4 more days\n Encourage C&DB, wean 02\n ^ activity as tol, get OOB, PT c/s\n Anemia, other\n Assessment:\n No evidence bleeding (liq stool, guiac neg). AM HCT stable at 37.5\n (32.9)\n Plan:\n Continue to monitor s/sx bleeding, goal HCT >30\n Altered mental status (not Delirium)\n Assessment:\n Pleasant and cooperative, A&Ox3. Speaking to relatives on phone.\n Difficult falling asleep. Requested sleep aid\n Action:\n 5mg ambient given. Safety/fall precautions maintained, pt encouraged to\n use call light for assistance prior to getting OOB to commode.\n Response:\n Slept well after\n Plan:\n Continue fall/safety precautions, re-orient PRN\n Provide calm environment, increase stimulation during the\n day to promote rest/sleep at night.\n" }, { "category": "Nursing", "chartdate": "2140-05-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455891, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revise, booked for\n tomorrow. So pt is NOT NPO she can eat, she will be injected and\n go down to scanner x2. Currently on heparin drip, she will transition\n to coumadin after all her procedures. She is on captopril ad\n carvedolol, tolerating her cardiac meds.\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n x 2 co of being tired but tolerated exercise.\n SR on monitor, no ectopy requiring Lasix to maintain u/o .Foley dc\n 11am,has voided 100cc since. nag 1200cc this am\n Right groin former balloon pump site c/d c old eccyhmosis r femoral\n site. Hct stable.on heparin 1750 units hr,therapeutic x 3. all distal\n pulses by Doppler, feet warm . Next PTT in the AM lab draw.\n Temp flat ,98.6 on levofloxin for pna ,sat 95 room air,crackles in base\n actually clear now.\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n No Cp, continues on heparin is going for viability study tomorrow,\n activity progressing and tolerating.\n Action:\n Ambulate today in unit, tolerated, on room air, no SOB\n Response:\n Tolerated activity, weaned off o2, tolerating ace and BB\n Plan:\n Increase activity as tolerated, may increase meds tomorrow?\n Shock, carcinogenic\n Assessment:\n BP stable\n Action:\n Continue meds check BP pre and post\n Response:\n Tolerating beta-blocker and ace, Vital signs stable\n Plan:\n Continue monitor\n ------ Protected Section ------\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n CORONARY ARTERY DISEASE;CHEST PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 81.5 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Precautions: No Additional Precautions\n PMH: Smoker\n CV-PMH: Arrhythmias, CAD, Hypertension, MI, Pacemaker, PVD\n Additional history: Organic heart disease S/p CABG x5 w/\n sequential SVG to LAD to Diag, sequential SVG to RPDA to posterolateral\n branch, & SVG to OM; s/p bilat subclavian stenting; VF arrest in \n d/t possible cocaine-induced CMP--> s/p PCM/ICD (changed in );\n hyperlipidemia; GERD; s/p tubal ligation; h/o carotid bruit; chronic\n BLE edema; non-compliant w/ meds; Tobacco use 1-2ppd til last month,\n possible COPD; prior ETOH & cocaine abuse--quit 7 yrs ago\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:72\n Temperature:\n 98.6\n Arterial BP:\n S:117\n D:96\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 988 mL\n 24h total out:\n 1,990 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:15 AM\n Potassium:\n 3.7 mEq/L\n 04:15 AM\n Chloride:\n 101 mEq/L\n 04:15 AM\n CO2:\n 24 mEq/L\n 04:15 AM\n BUN:\n 20 mg/dL\n 04:15 AM\n Creatinine:\n 1.0 mg/dL\n 04:15 AM\n Glucose:\n 96 mg/dL\n 04:15 AM\n Hematocrit:\n 37.5 %\n 04:15 AM\n Finger Stick Glucose:\n 105\n 05:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n ------ Protected Section Addendum Entered By: , RN\n on: 21:34 ------\n ------ Protected Section Addendum Entered By: , UC\n on: 08:25 ------\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455781, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc,booked for\n tomorrow\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n ..\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o .foley foley\n dc 11am,has voided 100ccsince. neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455793, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n S: pt reports new diarrhea (4BM/24hrs) after eating normal meals for\n the first time yesterday. Tolerating POs. No n/v or abdominal pain.\n No CP/SOB/F/C.\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: RA\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: wwp. trace pedal edema. Pulses +dop PT and DP bilat\n Neuro: A&Ox3.\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs:\n PT / PTT / INR:16.9/82.3/1.5,\n Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n CXR \n There is interval slight progression of the opacification of both lung\n bases that might be consistent with aspiration versus the\n underdevelopment of infectious process. Bilateral pleural effusions are\n most likely present, small-to-moderate. No evidence of overt pulmonary\n edema is seen. The patient is in mild interstitial engorgement. The\n right subclavian line tip is in mid SVC. No pneumothorax is present.\n Bilateral stents in the most likely\n subclavian and brachiocephalic arteries are present .\n MICRO:\n sputum from \n oropharengeal flora.\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI, likely\n secondary to SSVG to LAD occlusion based on OSH cath images on\n review. Mid LAD is occluded and there is a proximal LAD stenosis that\n supplies a moderate size diagonal, that on cath film appears to supply\n a viable, contracting territory. Her SVG to OM has in stent\n restenosis. Her SVG to PDA is patent.\n - uncertain whether PCI would provide benefit at this time\n - will otain viability study tomorrow (unable to get thalium today)\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt\n - cont captopril and carvedilol for afterload reduction (cont hold\n parameters to SBP 90)\n - heparin gtt for apical AK on TTE as bridge to coumadin; will start\n coumadin once decision in made re: possible PCI.\n .\n #. Respiratory failure: resolve. Pt satting well on room air. Resp\n failure was secondary to cardiogenic shock, extubated. Flashed\n yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora. Unlikely MRSA pneumonia. Not\n hospital acquired. Has defervesced and improved clinically.\n - cont levofloxacin 750mg x 5 days (day today)\n .\n #. Normocytic Anemia\n Hct 32 -> 37. Hct improved s/p aggressive\n diuresis over the past 2 days. Anemia was presumed IABP placement,\n hapto wnl, s/p 2 U PRBC\n -maintain Hct > 30\n .\n #. Access: 2 PIV\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines: D/C foley today\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT: on hep gtt\n Stress ulcer: d/c PPI\n Communication: Comments:\n Code status: Full code\n Disposition: call out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:36 ------\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455777, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc,booked for\n tomorrow\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n ..\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o .foley foley\n dc 11am,dtv 7pm . neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455778, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc,booked for\n tomorrow\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n ..\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o .foley foley\n dc 11am,dtv 7pm . neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455782, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc,booked for\n tomorrow\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n ..\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o .foley foley\n dc 11am,has voided 100cc since. neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455763, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc\n today pt alert ,ox3,pleasant .tol oob to chair but weak.\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o via foley .\n neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 2 pivs\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455764, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n ..\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o .foley foley\n dc 11am,dtv 7pm . neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455834, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revise, booked for\n tomorrow. So pt is NOT NPO she can eat, she will be injected and\n go down to scanner x2. Currently on heparin drip, she will transition\n to coumadin after all her procedures. She is on captopril ad\n carvedolol, tolerating her cardiac meds.\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n x 2 co of being tired but tolerated exercise.\n SR on monitor, no ectopy requiring Lasix to maintain u/o .Foley dc\n 11am,has voided 100cc since. nag 1200cc this am\n Right groin former balloon pump site c/d c old eccyhmosis r femoral\n site. Hct stable.on heparin 1750 units hr,therapeutic x 3. all distal\n pulses by Doppler, feet warm . Next PTT in the AM lab draw.\n Temp flat ,98.6 on levofloxin for pna ,sat 95 room air,crackles in base\n actually clear now.\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n No Cp, continues on heparin is going for viability study tomorrow,\n activity progressing and tolerating.\n Action:\n Ambulate today in unit, tolerated, on room air, no SOB\n Response:\n Tolerated activity, weaned off o2, tolerating ace and BB\n Plan:\n Increase activity as tolerated, may increase meds tomorrow?\n Shock, carcinogenic\n Assessment:\n BP stable\n Action:\n Continue meds check BP pre and post\n Response:\n Tolerating beta-blocker and ace, Vital signs stable\n Plan:\n Continue monitor\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455835, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revise, booked for\n tomorrow. So pt is NOT NPO she can eat, she will be injected and\n go down to scanner x2. Currently on heparin drip, she will transition\n to coumadin after all her procedures. She is on captopril ad\n carvedolol, tolerating her cardiac meds.\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n x 2 co of being tired but tolerated exercise.\n SR on monitor, no ectopy requiring Lasix to maintain u/o .Foley dc\n 11am,has voided 100cc since. nag 1200cc this am\n Right groin former balloon pump site c/d c old eccyhmosis r femoral\n site. Hct stable.on heparin 1750 units hr,therapeutic x 3. all distal\n pulses by Doppler, feet warm . Next PTT in the AM lab draw.\n Temp flat ,98.6 on levofloxin for pna ,sat 95 room air,crackles in base\n actually clear now.\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n No Cp, continues on heparin is going for viability study tomorrow,\n activity progressing and tolerating.\n Action:\n Ambulate today in unit, tolerated, on room air, no SOB\n Response:\n Tolerated activity, weaned off o2, tolerating ace and BB\n Plan:\n Increase activity as tolerated, may increase meds tomorrow?\n Shock, carcinogenic\n Assessment:\n BP stable\n Action:\n Continue meds check BP pre and post\n Response:\n Tolerating beta-blocker and ace, Vital signs stable\n Plan:\n Continue monitor\n ------ Protected Section ------\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n CORONARY ARTERY DISEASE;CHEST PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 81.5 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Precautions: No Additional Precautions\n PMH: Smoker\n CV-PMH: Arrhythmias, CAD, Hypertension, MI, Pacemaker, PVD\n Additional history: Organic heart disease S/p CABG x5 w/\n sequential SVG to LAD to Diag, sequential SVG to RPDA to posterolateral\n branch, & SVG to OM; s/p bilat subclavian stenting; VF arrest in \n d/t possible cocaine-induced CMP--> s/p PCM/ICD (changed in );\n hyperlipidemia; GERD; s/p tubal ligation; h/o carotid bruit; chronic\n BLE edema; non-compliant w/ meds; Tobacco use 1-2ppd til last month,\n possible COPD; prior ETOH & cocaine abuse--quit 7 yrs ago\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:72\n Temperature:\n 98.6\n Arterial BP:\n S:117\n D:96\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 988 mL\n 24h total out:\n 1,990 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:15 AM\n Potassium:\n 3.7 mEq/L\n 04:15 AM\n Chloride:\n 101 mEq/L\n 04:15 AM\n CO2:\n 24 mEq/L\n 04:15 AM\n BUN:\n 20 mg/dL\n 04:15 AM\n Creatinine:\n 1.0 mg/dL\n 04:15 AM\n Glucose:\n 96 mg/dL\n 04:15 AM\n Hematocrit:\n 37.5 %\n 04:15 AM\n Finger Stick Glucose:\n 105\n 05:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n ------ Protected Section Addendum Entered By: , RN\n on: 21:34 ------\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455759, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n S: pt reports new diarrhea (4BM/24hrs) after eating normal meals for\n the first time yesterday. Tolerating POs. No n/v or abdominal pain.\n No CP/SOB/F/C.\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: RA\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: wwp. trace pedal edema. Pulses +dop PT and DP bilat\n Neuro: A&Ox3.\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs:\n PT / PTT / INR:16.9/82.3/1.5,\n Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n CXR \n There is interval slight progression of the opacification of both lung\n bases that might be consistent with aspiration versus the\n underdevelopment of infectious process. Bilateral pleural effusions are\n most likely present, small-to-moderate. No evidence of overt pulmonary\n edema is seen. The patient is in mild interstitial engorgement. The\n right subclavian line tip is in mid SVC. No pneumothorax is present.\n Bilateral stents in the most likely\n subclavian and brachiocephalic arteries are present .\n MICRO:\n sputum from \n oropharengeal flora.\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI, likely\n secondary to SSVG to LAD occlusion based on OSH cath images on\n review. Mid LAD is occluded and there is a proximal LAD stenosis that\n supplies a moderate size diagonal, that on cath film appears to supply\n a viable, contracting territory. Her SVG to OM has in stent\n restenosis. Her SVG to PDA is patent.\n - uncertain whether PCI would provide benefit at this time\n - will otain viability study tomorrow (unable to get thalium today)\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt\n - cont captopril and carvedilol for afterload reduction (cont hold\n parameters to SBP 90)\n - heparin gtt for apical AK on TTE as bridge to coumadin; will start\n coumadin once decision in made re: possible PCI.\n .\n #. Respiratory failure: resolve. Pt satting well on room air. Resp\n failure was secondary to cardiogenic shock, extubated. Flashed\n yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora. Unlikely MRSA pneumonia. Not\n hospital acquired. Has defervesced and improved clinically.\n - cont levofloxacin 750mg x 5 days (day today)\n .\n #. Normocytic Anemia\n Hct 32 -> 37. Hct improved s/p aggressive\n diuresis over the past 2 days. Anemia was presumed IABP placement,\n hapto wnl, s/p 2 U PRBC\n -maintain Hct > 30\n .\n #. Access: 2 PIV\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines: D/C foley today\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT: on hep gtt\n Stress ulcer: d/c PPI\n Communication: Comments:\n Code status: Full code\n Disposition: call out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455831, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc,booked for\n tomorrow\n today pt alert ,ox3,pleasant .tol oob to chair,commode,ambulated in\n ..\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o .foley foley\n dc 11am,has voided 100ccsince. neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable.on heparin\n 1750 units hr,therapeutic x 3. all distal pulses by Doppler, feet warm\n .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 1piv.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455737, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc\n today pt alert ,ox3,pleasant .tol oob to chair but weak.\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o via foley .\n neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable all distal\n pulses by Doppler, feet warm .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n Pt having her period,sm amts of dk bloody,she states she is due for it\n at this time .\n 2 pivs\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455730, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc\n today pt alert ,ox3,pleasant .tol oob to chair but weak.\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o via foley .\n Iabp site c/d c old eccyhmosis r femoral site.all distal pulses by\n Doppler, only feet warm .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455732, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n dr. requested viability study p/t graft revasc\n today pt alert ,ox3,pleasant .tol oob to chair but weak.\n Sr no ect.tol bb and ace.requiring lasix to maintain u/o via foley .\n neg 1200cc this am\n Iabp site c/d c old eccyhmosis r femoral site. Hct stable all distal\n pulses by Doppler, only feet warm .\n Temp flat ,on levofloxin for pna ,sat 95 room air,crackles in base\n Good appetite.liq br neg stool ,cdiff neg x2 spec third spec sent today\n .\n" }, { "category": "Echo", "chartdate": "2140-04-30 00:00:00.000", "description": "Report", "row_id": 80194, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 67\nWeight (lb): 197\nBSA (m2): 2.01 m2\nBP (mm Hg): 105/52\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Depressed\nLVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nakinetic; mid inferoseptal - hypo; anterior apex - akinetic; septal apex-\nakinetic; inferior apex - akinetic; lateral apex - akinetic; apex -\ndyskinetic;\n\nRIGHT VENTRICLE: Indeterminate RV wall thickness. Normal RV chamber size.\nBorderline normal RV systolic function. [Intrinsic RV systolic function likely\nmore depressed given the severity of TR].\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral\nvalve supporting structures. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Moderate [2+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. LV systolic function is\ndepressed (ejection fraction 40-50 percent) secondary to extensive severe\napical akinesis with focal dyskinesis. The anterior septum and anterior free\nwall are severely hypokinetic/akinetic. The rest of the left ventricle is\nhyperdynamic. Tissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right\nventricular chamber size is normal. with borderline normal free wall function.\n[Intrinsic right ventricular systolic function is likely more depressed given\nthe severity of tricuspid regurgitation.] The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. Moderate [2+] tricuspid regurgitation is seen. However, due to\nextensive acoustic artifact from the right heart wire/catheter, the amount of\ntricuspid regurgitation may be inaccurately quantitated by color-flow imaging.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , extensive left ventricular contractile dysfunction now\npresent. A wire/catheter is seen crossing the tricuspid valve, and there is\nnow significant tricuspid regurgitation, possibly related to the\nwire/catheter.\n\n\n" }, { "category": "Physician ", "chartdate": "2140-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455305, "text": "Chief Complaint:\n 24 Hour Events:\n :\n - Weaned FiO2 to 40%\n - Started TFs and consulted nutrition\n - Attempted to wean sedation, however patient very agitated\n - Gave 20mg of IV lasix at 12:30\n - Able to wean IABP to 1:2 without need of pressors, on 1:4 overnight\n without problem, plan to stop heparin at 3am and put back at 1:1 in\n anticipation of discontinuing\n - Hct 30 at 2:30pm\n - Confirmed placement of IABP with fluroscopy\n - Planned to resite line, however as pt not tolerating manipulation and\n likely patient will not need triple lumen for more than 24 hours, will\n plan on keeping subclavian and attempt to place PIV\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.7\n HR: 77 (63 - 87) bpm\n BP: 115/72(92) {78/35(58) - 128/97(100)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (8 - 294)mmHg\n Total In:\n 1,421 mL\n 120 mL\n PO:\n TF:\n IVF:\n 751 mL\n 120 mL\n Blood products:\n 610 mL\n Total out:\n 2,227 mL\n 85 mL\n Urine:\n 2,227 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n -806 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 580 (580 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 53\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/39/95./20/-2\n Ve: 9.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 331 K/uL\n 11.3 g/dL\n 83 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 110 mEq/L\n 141 mEq/L\n 33.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n 02:23 PM\n 02:40 PM\n 05:26 PM\n 04:26 AM\n 04:44 AM\n WBC\n 6.9\n 7.5\n 8.7\n Hct\n 23.7\n 27.7\n 30.3\n 33.0\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n TropT\n 2.52\n TCO2\n 22\n 23\n 24\n 22\n 23\n Glucose\n 99\n 97\n 83\n Other labs: PT / PTT / INR:13.7/38.8/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Imaging: TTE: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. LV\n systolic function is depressed (ejection fraction 40-50 percent)\n secondary to extensive severe apical akinesis with focal dyskinesis.\n The anterior septum and anterior free wall are severely\n hypokinetic/akinetic. The rest of the left ventricle is hyperdynamic.\n Tissue Doppler imaging suggests an increased left ventricular filling\n pressure (PCWP>18mmHg). There is no ventricular septal defect. Right\n ventricular chamber size is normal. with borderline normal free wall\n function. [Intrinsic right ventricular systolic function is likely more\n depressed given the severity of tricuspid regurgitation.] The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve appears\n structurally normal with trivial mitral regurgitation. Moderate [2+]\n tricuspid regurgitation is seen. However, due to extensive acoustic\n artifact from the right heart wire/catheter, the amount of tricuspid\n regurgitation may be inaccurately quantitated by color-flow imaging.\n There is moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n Compared with the findings of the prior report (images unavailable for\n review) of , extensive left ventricular contractile\n dysfunction now present. A wire/catheter is seen crossing the tricuspid\n valve, and there is now significant tricuspid regurgitation, possibly\n related to the wire/catheter.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n ANEMIA, OTHER\n PNEUMONIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455538, "text": "Chief Complaint:\n 24 Hour Events:\n - IABP pulled\n - Extubated\n - Started captopril and uptitrated for afterload reduction\n - Pm Hct stable\n - PM lytes with K 3.6 so repleted then with more lasix for extubation\n had K 3.3 so received more K\n - Temp 100.1 and sputum with 3+ GPCs and strep pneumo from OSH cultures\n so started vanc/zosyn\n - Got 20mg lasix IV X1 prior to extubation for frothy secretions\n although UOP good after the first dose in the am\n - Restarted hep gtt at 4pm for apical AK on TTE (will need transition\n to coumadin prior to discharge)\n - Started coreg as HRs in 90s and BPs 150s/80s\n - Delirious overnight and suspect ICU psychosis. Zyprexa given and did\n not respond so got haldol.\n - Flashed at 2am with BPs 180s/120s, tachypnea to 30s, and HR 120s with\n tiny drop in sats responded to nitro gtt, morphine (2mg), and\n non-invasive mask ventilation. Got 40mg IV lasix with only 20ml out so\n got 80mg as CXR looked like more pulm edema (although poor film) -> put\n out 2L (from AM). EKG with inferior ST depressions and little\n longer QT with continued STE V1-V3 as in prior.\n .\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Nitroglycerin - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 AM\n Heparin Sodium - 11:26 PM\n Haloperidol (Haldol) - 02:00 AM\n Morphine Sulfate - 02:18 AM\n Furosemide (Lasix) - 03:00 AM\n Other medications: ASA 325, plavix 75, atorvastatin 80, HISS<\n pantoprazole 40, colace, captopril 12.5, carvedilol 3.125mg \n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 103 (72 - 123) bpm\n BP: 116/66(76) {92/50(67) - 191/125(125)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 89-100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 6 (5 - 304)mmHg\n Total In:\n 1,590 mL\n 597 mL\n PO:\n TF:\n IVF:\n 1,590 mL\n 597 mL\n Blood products:\n Total out:\n 2,997 mL\n 1,093 mL\n Urine:\n 2,997 mL\n 1,093 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,407 mL\n -496 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 512 (512 - 670) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/37/334/25/0\n Ve: 11.8 L/min\n PaO2 / FiO2: 668\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: tr pedal edema\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 408 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.9 %\n 8.1 K/uL\n [image002.jpg]\n 04:26 AM\n 04:44 AM\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n WBC\n 8.7\n 8.1\n Hct\n 33.0\n 31.5\n 32.9\n Plt\n 331\n 408\n Cr\n 0.7\n 0.8\n 0.8\n TCO2\n 23\n 23\n 24\n 19\n 20\n 24\n Glucose\n 83\n 101\n Other labs: PT / PTT / INR:15.6/80.0/1.4, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n - cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would provide benefit at this time\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2, day #4 of antibiotics.\n - discontinue vanc and zosyn for now\n - start levofloxacin 750mg x 5 days\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today and place PICC\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455553, "text": "Chief Complaint:\n 24 Hour Events:\n - IABP pulled\n - Extubated\n - Started captopril and uptitrated for afterload reduction\n - Pm Hct stable\n - PM lytes with K 3.6 so repleted then with more lasix for extubation\n had K 3.3 so received more K\n - Temp 100.1 and sputum with 3+ GPCs and strep pneumo from OSH cultures\n so started vanc/zosyn\n - Got 20mg lasix IV X1 prior to extubation for frothy secretions\n although UOP good after the first dose in the am\n - Restarted hep gtt at 4pm for apical AK on TTE (will need transition\n to coumadin prior to discharge)\n - Started coreg as HRs in 90s and BPs 150s/80s\n - Delirious overnight and suspect ICU psychosis. Zyprexa given and did\n not respond so got haldol.\n - Flashed at 2am with BPs 180s/120s, tachypnea to 30s, and HR 120s with\n tiny drop in sats responded to nitro gtt, morphine (2mg), and\n non-invasive mask ventilation. Got 40mg IV lasix with only 20ml out so\n got 80mg as CXR looked like more pulm edema (although poor film) -> put\n out 2L (from AM). EKG with inferior ST depressions and little\n longer QT with continued STE V1-V3 as in prior.\n .\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Nitroglycerin - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 AM\n Heparin Sodium - 11:26 PM\n Haloperidol (Haldol) - 02:00 AM\n Morphine Sulfate - 02:18 AM\n Furosemide (Lasix) - 03:00 AM\n Other medications: ASA 325, plavix 75, atorvastatin 80, HISS<\n pantoprazole 40, colace, captopril 12.5, carvedilol 3.125mg \n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 103 (72 - 123) bpm\n BP: 116/66(76) {92/50(67) - 191/125(125)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 89-100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 6 (5 - 304)mmHg\n Total In:\n 1,590 mL\n 597 mL\n PO:\n TF:\n IVF:\n 1,590 mL\n 597 mL\n Blood products:\n Total out:\n 2,997 mL\n 1,093 mL\n Urine:\n 2,997 mL\n 1,093 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,407 mL\n -496 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 512 (512 - 670) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/37/334/25/0\n Ve: 11.8 L/min\n PaO2 / FiO2: 668\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: tr pedal edema\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 408 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.9 %\n 8.1 K/uL\n [image002.jpg]\n 04:26 AM\n 04:44 AM\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n WBC\n 8.7\n 8.1\n Hct\n 33.0\n 31.5\n 32.9\n Plt\n 331\n 408\n Cr\n 0.7\n 0.8\n 0.8\n TCO2\n 23\n 23\n 24\n 19\n 20\n 24\n Glucose\n 83\n 101\n Other labs: PT / PTT / INR:15.6/80.0/1.4, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n - cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would provide benefit at this time\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2, day #4 of antibiotics.\n - discontinue vanc and zosyn for now\n - start levofloxacin 750mg x 5 days\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today and place PICC\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P. IABP successfully weaned and patient extubated.\n We plan supportive care with ischemia, viability study when she is\n stronger to assess need for revascularization. 60 minutes spent on\n patient critical care. ICU level care due to cardiogenic shock, recent\n intubation, compromised respiratory status.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:07 ------\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455556, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455558, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Altered mental status (not Delirium)\n Assessment:\n PT SLEEPING ALL DAY NO SEDATION GIVEN SINCE NIGHT SHIFT .RESPONDS TO\n NAME,STATES SHE IS IN THE HOSPITAL.ASKED FOR ICE CREAM,TAKING CL\n LIQUIDS AT PRESENT .HUSBAND VISITING ,SPOKE TO DR\n :\n FOLLOWING NEURO STATUS,MAINTAINING SAFETY\n Response:\n PT NOT TRYING TO GET OOB\n Plan:\n MAINTAIN SAFETY ,MINIMAL SEDATION\n Shock, cardiogenic\n Assessment:\n PT 2 LITERS ,RALES IN BASES . SAT 97 0N 4L NP .SR 60S,BP\n MARGINAL .PARAMETERS CHANGED ON BP TO 95 ,CARVEDIAL GIVEM BP 80S .WILL\n CHECK BEFORE GIVING ACE.. PERIPHERALS PLACED .R SUCLAVIAN TO BE DC .R\n ARM TENDER AND SWOLLEN THAN L,WARM,PULSES BY DOPPLER. NO BLEEDING\n FROM IABP SITE,DISTAL PULSES BY DOPPLER\n Action:\n MONITOR BP IN RESPONSE TO MEDS.MONITOR FLUID STATUS.PTT 80 ON 1750\n UNITS HEPARIN\n Response:\n STABLE\n Plan:\n CARDIAC MEDS AS TOL ,FOLLOW LYTES ,PTT\n Anemia, other\n Assessment:\n NO EVIDENCE OF BLEEDING\n Action:\n FOLLOW HCT,MONITOR FOR BLEEDING\n Response:\n HCT STABLE 32\n Plan:\n OBSERVE FOR BLEEDING\n Pneumonia, other\n Assessment:\n AFEBRILE,WEAK COUGH ,ANTIBIOTICS CHANGED TO LEVOFLOXIN\n Action:\n ENCOURAGE TCDB,MAINTAIN O2 SAT\n Response:\n STABLE\n Plan:\n WEAN O2,FOLLOW TEMP ANTIBIOTICS AS TOL\n" }, { "category": "Nutrition", "chartdate": "2140-05-02 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 455559, "text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 3\n days. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Comments:\n 49 yo woman with known CAD s/p cabg, ICD and cardiogenic shock in\n setting of anterior MI, pt extubated and started on clear liquid today,\n will f/u re intakes/diet advance. please page if has ?\n" }, { "category": "Physician ", "chartdate": "2140-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455523, "text": "Chief Complaint:\n 24 Hour Events:\n - IABP pulled\n - Extubated\n - Started captopril and uptitrated for afterload reduction\n - Pm Hct stable\n - PM lytes with K 3.6 so repleted then with more lasix for extubation\n had K 3.3 so received more K\n - Temp 100.1 and sputum with 3+ GPCs and strep pneumo from OSH cultures\n so started vanc/zosyn\n - Got 20mg lasix IV X1 prior to extubation for frothy secretions\n although UOP good after the first dose in the am\n - Restarted hep gtt at 4pm for apical AK on TTE (will need transition\n to coumadin prior to discharge)\n - Started coreg as HRs in 90s and BPs 150s/80s\n - Delirious overnight and suspect ICU psychosis. Zyprexa given and did\n not respond so got haldol.\n - Flashed at 2am with BPs 180s/120s, tachypnea to 30s, and HR 120s with\n tiny drop in sats responded to nitro gtt, morphine (2mg), and\n non-invasive mask ventilation. Got 40mg IV lasix with only 20ml out so\n got 80mg as CXR looked like more pulm edema (although poor film) -> put\n out 2L (from AM). EKG with inferior ST depressions and little\n longer QT with continued STE V1-V3 as in prior.\n .\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Nitroglycerin - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 AM\n Heparin Sodium - 11:26 PM\n Haloperidol (Haldol) - 02:00 AM\n Morphine Sulfate - 02:18 AM\n Furosemide (Lasix) - 03:00 AM\n Other medications: ASA 325, plavix 75, atorvastatin 80, HISS<\n pantoprazole 40, colace, captopril 12.5, carvedilol 3.125mg \n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 103 (72 - 123) bpm\n BP: 116/66(76) {92/50(67) - 191/125(125)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 89-100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 6 (5 - 304)mmHg\n Total In:\n 1,590 mL\n 597 mL\n PO:\n TF:\n IVF:\n 1,590 mL\n 597 mL\n Blood products:\n Total out:\n 2,997 mL\n 1,093 mL\n Urine:\n 2,997 mL\n 1,093 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,407 mL\n -496 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 512 (512 - 670) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/37/334/25/0\n Ve: 11.8 L/min\n PaO2 / FiO2: 668\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: tr pedal edema\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 408 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.9 %\n 8.1 K/uL\n [image002.jpg]\n 04:26 AM\n 04:44 AM\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n WBC\n 8.7\n 8.1\n Hct\n 33.0\n 31.5\n 32.9\n Plt\n 331\n 408\n Cr\n 0.7\n 0.8\n 0.8\n TCO2\n 23\n 23\n 24\n 19\n 20\n 24\n Glucose\n 83\n 101\n Other labs: PT / PTT / INR:15.6/80.0/1.4, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n -cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently,\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2\n -cont vanc and zosyn for now\n -f/u OSH culture data, narrow as able\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-04-30 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 455139, "text": "Chief Complaint: transfer from OSH for cardiogenic shock\n HPI:\n 49 y/o F w/ prior CABG (SVG to the OM, SVG to PDA/LPL, SVG to\n Diag/LAD), multiple peripheral interventions, prior VF arrest and ICD\n placement, who is transferred from an OSH for cardiogenic shock.\n .\n Patient initially presented on with chest pain. She reported\n that she developed increasing episodes of chest discomfort with walking\n in the 1-2 weeks prior to presenation. On the night prior to\n presentation, she developed chest discomfort at 9pm. She felt this to\n be GERD and so went to sleep, but woke up all night with chest pain.\n She described the pain as radiating to her right shoulder and right arm\n (but not left arm). She took some out of date nitro she had available\n w/o improvement. The following morning she attempted to get a new\n nitro prescription at the pharmacy which rapidly helped her pain\n improve, but it quickly returned and was never completely pain free.\n She presented to the ED approximately 12 hours after the onset of her\n pain the night before.\n .\n In the OSH ED she was reported to have ST elevation in V2 2mm and ST\n elevation in V1/V3. Bedside Echo demonstrated hypokinetic/akinetic\n mid-distal anterior septum, basal and distal anterior wall, and entire\n apex. EF 35% (previous EF in - 60%). Patient was started on\n metoprolol, integrilin, nitroglycerin, and heparin gtt and was never\n chest pain free. Patient was transfered to Center for\n emergent catheterization.\n .\n On arrival at Center, patient was cath'd but no\n intervention was performed(report not available - images not yet\n reviewed). On cath found VG to OM with stent, unchanged from previous,\n VG to PDA patent with collaterals to distal LAD, VG to LAD occluded\n with proximal thrombus (previously patent in ). Patient was\n managed medically.\n .\n After presentation patient was on the medical floor, and developed what\n was reportedly completed heart block and cariogenic shock. Repeat Echo\n showed extension of her infarct with EF 20-25%, and new RV\n dysfunction. She was intubated, started on dopamine and placed on\n IABP. She was taken back to the lab where gain no intervenable lesion\n was identified (report unavailable - images not yet reviewed). No\n apparent change on cath but will need to review images. She was then\n taken back to the ICU on pressors. Over next 2-3 days where she was\n weaned of pressors but could not be weaned off dopamine and IABP. She\n was then transferred to for mgmt.\n .\n ICU course was otherwise notable for poor LE pulses with intermittent\n loss of pulses. Patient was treated for strep pneumonia with\n ceftriaxone (unclear how many days of therapy).\n .\n ROS: n/a\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CABG in (SVG to the OM, SVG to PDA/LPL, SVG to Diag/LAD)\n -Subclavian stenosis, s/p right brachiocephalic/subclavian\n stenting ()\n -R-Brachiocephalic artery stenosis s/p stent \n - s/p cardiac arrest, s/p ICD\n -Prior cocaine abuse, stopped 7 years ago\n -Prior ETOH abuse, stopped 7 years ago\n -C-section\n -Tobacco abuse 1-2ppd up until last month\n -Pneumonia \n -non-compliant with medications\n -h/o R-carotid bruit.\n -Possible h/o COPD\n ---------------------------\n Cardiac Risk Factors: Dyslipidemia\n .\n ALLERGIES: Codeine/hydrocodone/morphine\n ----------------------------\n CURRENT MEDICATIONS:\n (Medications on initial presentation)\n Aspirin 325\n Plavix 75\n Lipitor 40\n Reportedly non-compliant with meds in the past, but taking\n aspirin/plavix.\n .\n (Medications on transfer)\n Albuterol PRN\n Colace 100mg \n Aspirin 325mg daily\n Protonix 40mg IV daily\n heparin gtt\n ceftriaxone 2gm q24\n dopamine gtt\n propofol gtt\n (+) FHx CAD. Father and grandfather both with\n in their 40's. Father with a stroke at age 70.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, works as a real estate in NH. Prior cocaine/ETOH\n abuse. 1-2ppd up until last month. No reported etoh abuse recently.\n Review of systems:\n Flowsheet Data as of 01:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 76 (67 - 76) bpm\n BP: 117/78(93) {94/53(74) - 117/96(102)} mmHg\n RR: 21 (16 - 2,355,555) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 102 mL\n 28 mL\n PO:\n TF:\n IVF:\n 102 mL\n 28 mL\n Blood products:\n Total out:\n 568 mL\n 31 mL\n Urine:\n 68 mL\n 31 mL\n NG:\n Stool:\n Drains:\n Balance:\n -466 mL\n -3 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: 7.41/33/95./19/-2\n Ve: 12.1 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Lungs: clear anteriorly\n Abdomen: Softly distended, +BS, no organomegaly appreciated\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Skin: Not assessed\n Neurologic: withdraws to pain, tracks to voice, but does not follow\n commands\n Labs / Radiology\n 262 K/uL\n 8.1 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 9 mg/dL\n 19 mEq/L\n 114 mEq/L\n 4.0 mEq/L\n 141 mEq/L\n 23.7 %\n 6.9 K/uL\n [image002.jpg]\n \n 2:33 A4/24/ 09:20 PM\n \n 10:20 P4/24/ 09:40 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.9\n Hct\n 23.7\n Plt\n 262\n Cr\n 0.6\n TropT\n 2.52\n TC02\n 22\n Glucose\n 99\n Other labs: PT / PTT / INR:14.0/40.3/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:66/73, Alk Phos / T Bili:119/0.3,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n .\n LABORATORY DATA: from OSH\n WBC 9.0, Hct 26.4, Hgb 8.6, Plt 227\n Cr 0.8, CO2 20, Cl 113, Gluc 105, Na 141,\n Troponin 33.6 (nml < 0.04), CK 841, MB fraction 24\n Alk Phos 127, albumin 2.2, ALT 78, AST 113, Total Protein 6.4\n LDL 81, Total Chol 126,\n HCG negative\n .\n Imaging:\n EKG : sinus rhythm with nml intervals, nml axis, no hypertrophy,\n with anterior ST elevation in V1-V4 with TWI in precordial leads and\n TWF in I/aVL/III\n EKG : unchanged.\n .\n EKG: Sinus rhythm, low voltage in limb leads, nml axis, nml\n intervals, ST elevation in V2/V3, TWI in V6/III/aVF\n .\n TELEMETRY: n/a\n .\n 2D-ECHOCARDIOGRAM performed on demonstrated:\n The left atrium is normal in size. The left ventricular cavity size is\n normal. Overall left ventricular systolic function is normal LVEF>55%).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets appear structurally normal with good leaflet\n excursion. The aortic valve is not well seen. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Mild (1+) mitral regurgitation is seen. The\n pulmonary artery systolic pressure could not be determined. There is no\n pericardial effusion.\n .\n Echo :\n 1. Anteroapical hypokinesis with EF 40-45%, apex is hypokinetic.\n .\n Echo :\n 1. EF 20-25%, basal segments of LV best preserved with otherwise\n severe decrease in LV systolic function, reduced RV systolic function,\n mild MR, moderate TR, moderate pulmonary hypertension.\n .\n Echo : Wet read: depressed EF, basal segments of LV with best\n residual function.\n .\n No Stress available\n .\n CARDIAC CATH performed on demonstrated:\n 1. Mild in-stent restenosis of the stents in the right subclavian\n artery and brachiocephalic arteries.\n 2. Mild in-stent restenosis of the stent in the left subclavian artery.\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n .\n #. Cardiogenic Shock: to MI. Likely some component of RV infarct\n given echo findings from , severe hypotension, and\n heartblock/bradycardia on presentation. Stable on balloon pump\n currently and low dose pressors. If unable to wean from IABP would\n need to consider transplant or other intervention.\n - wean dopamine as tolerated\n - wean IABP as tolerated\n - follow UOP and goal MAP>60\n - heparin gtt with balloon\n - afterload reduction as tolerated\n - echo in AM\n .\n #. CAD: Severe multivessel disease, now s/p STEMI\n - review OSH cath films\n - aspirin 325\n - plavix 75mg\n - lipitor 80\n - heparin gtt for balloon pump\n - consider return to lab\n - check A1c\n - HCT>30\n .\n #. Respiratory: Intubated.\n - fentanyl/versed for sedation\n .\n #. LE Pulses: dopplerable pulses on arrival. Follow LE pulses closely\n given h/o intermittent loss of pulses at OSH.\n - serial pulse checks\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n #. PVD: Stable\n .\n #. Pneumonia: No h/o fevers, sputum production or focal infiltrate\n - send blood culture/sputum culture\n - CXR\n - hold antibiotics overnight\n .\n #. Anemia: normocytic. Not addressed in OSH records.\n - check ferritin, hapto and LDH\n - guaiac stools\n - type and cross\n - goal HCT > 30\n .\n #. Cocaine Use: Not actively using.\n .\n #. FEN: Replete lytes prn\n .\n #. Access: will need to change a-line, CVL in next 24 hours.\n .\n #. PPx: heparin gtt, bowel regimen prn\n .\n #. Emergency contact:\n .\n #. Code: full\n .\n #. Dispo: Pending resolution of above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: ppi\n VAP: chlorhexedine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2140-04-29 00:00:00.000", "description": "Cardiology Fellow Addendum to Housestaff admission", "row_id": 455130, "text": "TITLE: Cardiology Fellow Addendum\n Pt seen and examined, agree with housestaff note\n Chart from OSH reviewed\n Briefly, ms. is a 49 yo woman with CAD s/p cabg in , vf\n arrest s/p ICD, pvd s/p multiple interventions on subclavian arteries\n who presented to an osh with 12 hours of stuttering chest pain\n and anterior st elevations. She was cath\nd without intervention. She\n was being medically managed on floor but after two days decompensated\n with CHF requiring intubation and hypotension. She went back to\n cath lab and again no intervention but IABP was placed and dopamine\n started. She was transferred for further management.\n On arrival, ms. was intubated, sedated on 1 of dopamine and\n IABP at 1:1. She was unable to provide a history or ROS.\n VS: MAP\ns in the 60\ns off dopamine, hr 76\n Intubated, sedated\n r. subcl. Line.\n RRR nl s1s2 no mrg\n CTA ant/lat\n Warm extremities with no edema\n Doppler pulses distally\n Abd soft non tender\n IABP in r. groin\n Labs reviewed\n ECG sinus with improved st elevations ant.\n Cath films from OSH reviewed: Native vessels: LAD occluded mid, LCx\n patent with diffuse disease, RCA occluded. SVG-PDA patent, SVG-OM\n patent with proximal stent that has unchanged ISRS, SVG-LAD occluded\n with haziness (thrombus??). In the SVG-LAD graft was patent. There\n are collaterals from PDA to LAD territory.\n A/P 49 yo woman with known CAD s/p cabg, ICD and cardiogenic shock in\n setting of anterior MI\n 1. Anterior MI\n at this point she has not been reperfused. Will\n assess possibilities (redo cabg vs. pci on svg vs med therapy).\n Cont ASA, heparin. Recheck echo in am, assess for apical clot.\n Statin, bblocker if bp stabilizes. Continue to monitor for\n arrhythmias\n 2. Cardiogenic shock\n due to MI. Dopamine weaned. Cont IABP at 1:1\n for tonight. need acei to help wean iabp as hemodynamics\n improve. CXR daily, heparin gtt.\n 3. Rest of plan per housestaff\n 4. D/W attending who agrees with plan.\n 23:43\n" }, { "category": "Physician ", "chartdate": "2140-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455215, "text": "Chief Complaint:\n 24 Hour Events:\n - 2 u prbc\n - difficult to confirm IABP placement\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 78 (67 - 80) bpm\n BP: 122/75(90) {94/53(74) - 122/96(102)} mmHg\n RR: 20 (16 - 2,355,555) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 102 mL\n 430 mL\n PO:\n TF:\n IVF:\n 102 mL\n 130 mL\n Blood products:\n 300 mL\n Total out:\n 568 mL\n 81 mL\n Urine:\n 68 mL\n 81 mL\n NG:\n Stool:\n Drains:\n Balance:\n -466 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n SpO2: 98%\n ABG: 7.38/37/151/19/-2\n Ve: 9.6 L/min\n PaO2 / FiO2: 302\n Physical Examination\n Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 255 K/uL\n 9.4 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 114 mEq/L\n 141 mEq/L\n 27.7 %\n 7.5 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n WBC\n 6.9\n 7.5\n Hct\n 23.7\n 27.7\n Plt\n 262\n 255\n Cr\n 0.6\n TropT\n 2.52\n TCO2\n 22\n 23\n Glucose\n 99\n Other labs: PT / PTT / INR:14.0/40.3/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:66/73, Alk Phos / T Bili:119/0.3,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to MI. Currently on IABP and off dopa.\n - Will attempt to wean IABP as tolerated following eval of OSH records\n to determine if required for coronary perfusion;\n - may need dobutamine for afterload reduction if decide to wean IABP,\n goal MAP 60, UOP 20cc/hr\n - heparin gtt and CXR daily with balloon\n - echo today to evaluate for progression of wall motion abnormality, to\n eval for anterior wall viability\n - Check pulses frequently with IABP in place\n #. CAD: Severe multivessel disease, now s/p STEMI\n - Continue IABP to increase coronary perfusion\n - Will eval outside hospital cath reports, may need intervention here\n if determine anterior wall has viability\n - aspirin 325, plavix 75mg, lipitor 80, heparin gtt\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs)\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX for now, will start empirically for HAP or VAP if has leukocytosis\n or CXR findings of infiltrate\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n #. FEN: Replete lytes prn\n #. Access: will need to change a-line, CVL in next 24 hours.\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n #. Code: full\n #. Dispo: Pending resolution of above\n ICU Care\n Nutrition: NPO for now, will need TFs if remains intubated\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:30 PM OSH\n Multi Lumen - 08:30 PM OSH\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined on CCU rounds with\n the team. I have also personally reviewed her cardiac catheterization\n films from the OSH. I agree with the notes of Dr. and\n Dr. , including their H+P, A+P. Acute anterior myocardial\n infarction several days ago that appears secondary to SVG to LAD\n occlusion. Her mid LAD is occluded. She has a proximal LAD stenosis\n that supplies a moderate size diagonal, that on cath film appears to\n supply a viable, contracting territory. Her SVG to OM has in stent\n restenosis. Her SVG to PDA is patent.\n The patient is currently on IABP with acceptable hemodynamics and\n oxygen saturations. We plan diuresis, pressor support\n (dopamine/dobutamine) as needed as we attempt to wean IABP. There is\n no indication at this time for urgent cath or PCI. 90 minutes spent on\n patient critical care. ICU level care due to intubation and IABP.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:12 ------\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455471, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Off IABP since yesterday on days. Pt started on Coreg for HRin low 100.\n IVNTG wean off , pt started on captopril. Poor u/o (as low\n as10-15cc/hr) last evening, reported to Drs. and . At\n this time pt neg 1900cc and w/ low grade temp 100.3.IV fluid bolus\n ordered.\n Action:\n Fluid bolus given, u/o w/o good response.\n Response:\n 0210 pt tachypneic and w/ labored breathing, MHR up to 120s ST, SPB up\n to 190s. sats 97%, bs diminished and w/ expir wheezes bilat. Pt\n restarted on IV NTG, lasix 40mg given w/o affect. And started on mask\n ventilation. Repeat lasix of 80mgs given. Pt diuresing for 2^nd dose of\n Lasix. Potassium replaced last evening. MHR down to 80s. BP trending\n down to >60mmhg\n Plan:\n IV NGT wean off for MAP < 60mmHg. Heparin at 1750units /hr. w/\n therapeutic PTT 80\n Altered mental status (not Delirium)\n Assessment:\n Pt emotional labile, teary then yelling out profanities to saying thank\n you for ice chips. Oriented to self, verbalized that she is in but speech difficult to understand at times. Weak hand grips\n bilaterally. Face symmetrical. Moving legs all over bed and over side\n rail. Attemped to get oob x2\n Action:\n Pt received Zyprexa 5mg x2 w/ less agitated for about an hour.\n Response:\n Pt became agitatied again , in acute delirium received Haldol 2mg x2\n Plan:\n Inquire regarding ETOH abuse when speaking to the family . continue\n falls prevention.\n Pneumonia, other\n Assessment:\n + sputum cultures\n Action:\n Pt remains on Vnco and Zosyn.\n Response:\n Congested cough. Not expectorationg.\n Plan:\n Continue antibiotics, monitor temperature, WBC\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455473, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Off IABP since yesterday on days. Pt started on Coreg for HRin low 100.\n IVNTG wean off , pt started on captopril. Poor u/o (as low\n as10-15cc/hr) last evening, reported to Drs. and . At\n this time pt neg 1900cc and w/ low grade temp 100.3.IV fluid bolus\n ordered.\n Action:\n Fluid bolus given, u/o w/o good response.\n Response:\n 0210 pt tachypneic and w/ labored breathing, MHR up to 120s ST, SPB up\n to 190s. sats 97%, bs diminished and w/ expir wheezes bilat. Pt\n restarted on IV NTG, lasix 40mg given w/o affect. And started on mask\n ventilation. Repeat lasix of 80mgs given. Pt diuresing for 2^nd dose of\n Lasix. Potassium replaced last evening. MHR down to 80s. BP trending\n down to >60mmhg. Mask Ventilation on for a brief time. See flow sheet.\n Plan:\n IV NGT wean off for MAP < 60mmHg. Heparin at 1750units /hr. w/\n therapeutic PTT 80. ptt due at 11 am.\n Altered mental status (not Delirium)\n Assessment:\n Pt emotional labile, teary then yelling out profanities to saying thank\n you for ice chips. Oriented to self, verbalized that she is in but speech difficult to understand at times. Weak hand grips\n bilaterally. Face symmetrical. Moving legs all over bed and over side\n rail. Attemped to get oob x2\n Action:\n Pt received Zyprexa 5mg x2 w/ less agitated for about an hour.\n Response:\n Pt became agitatied again , in acute delirium received Haldol 2mg x2\n Plan:\n Inquire regarding ETOH abuse when speaking to the family . continue\n falls prevention.\n Pneumonia, other\n Assessment:\n + sputum cultures, T max 100.3 , now afebrile. WBC 8.1 this am.\n Action:\n Pt remains on Vnco and Zosyn.\n Response:\n Congested cough. Not expectorationg.\n Plan:\n Continue antibiotics, monitor temperature, WBC\n Anemia, other\n Assessment:\n Hct this am 32.9.\n Action:\n Continue to monior for sings of bleeding\n Response:\n Remains stable\n Plan:\n Monitor HCT.\n" }, { "category": "Physician ", "chartdate": "2140-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455479, "text": "Chief Complaint:\n 24 Hour Events:\n - IABP pulled\n - Started captopril and uptitrated for less afterload\n - Pm Hct stable\n - PM lytes with K 3.6 so repleted then with more lasix for extubation\n had K 3.3 so received more K.\n - Temp 100.1 and sputum with 3+ GPCs and strep pneumo from OSH cultures\n so started vanc/zosyn\n - Got 20mg lasix IV X1 prior to extubation for frothy secretions\n although UOP good after the first dose in the am\n - Restarted hep gtt at 4pm for apical AK on TTE (will need transition\n to coumadin prior to discharge)\n - Extubated\n - STarted coreg as HRs in 90s and BPs 150s/80s\n - Delirious overnight and suspect ICU psychosis. Zyprexa given and did\n not respond so got haldol.\n - Flashed at 2am with BPs 180s/120s, tachypnea to 30s, and HR 120s with\n tiny drop in sats responded to nitro gtt, morphine (2mg), and\n non-invasive mask ventilation. Got 40mg IV lasix with only 20ml out so\n got 80mg as CXR looked like more pulm edema (although poor film). EKG\n with inferior ST depressions and little longer QT with continued STE\n V1-V3 as in prior.\n .\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Nitroglycerin - 0.25 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 AM\n Heparin Sodium - 11:26 PM\n Haloperidol (Haldol) - 02:00 AM\n Morphine Sulfate - 02:18 AM\n Furosemide (Lasix) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 103 (72 - 123) bpm\n BP: 116/66(76) {92/50(67) - 191/125(125)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 6 (5 - 304)mmHg\n Total In:\n 1,590 mL\n 597 mL\n PO:\n TF:\n IVF:\n 1,590 mL\n 597 mL\n Blood products:\n Total out:\n 2,997 mL\n 1,093 mL\n Urine:\n 2,997 mL\n 1,093 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,407 mL\n -496 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 512 (512 - 670) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.40/37/334/25/0\n Ve: 11.8 L/min\n PaO2 / FiO2: 668\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 408 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.9 %\n 8.1 K/uL\n [image002.jpg]\n 04:26 AM\n 04:44 AM\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n WBC\n 8.7\n 8.1\n Hct\n 33.0\n 31.5\n 32.9\n Plt\n 331\n 408\n Cr\n 0.7\n 0.8\n 0.8\n TCO2\n 23\n 23\n 24\n 19\n 20\n 24\n Glucose\n 83\n 101\n Other labs: PT / PTT / INR:15.6/80.0/1.4, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to large acute anterior myocardial\n infarction. Currently on IABP with plan to wean to pull this AM\n - As IABP is not required for coronary perfusion and blood pressures\n stable on 1:4, will pull this AM\n - unlikely to require dobutamine for afterload reducing as pressures\n remained stable on 1:4\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will needcoumadin prior to d/c for\n apical AK.\n - Check pulses frequently with IABP in place but will be d/c\nd today\n #. CAD: Severe multivessel disease, now s/p STEMI acute anterior wall,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Otherwise her mid LAD is occluded and\n there is a proximal LAD stenosis that supplies a moderate size\n diagonal, that on cath film appears to supply a viable, contracting\n territory. Her SVG to OM has in stent restenosis. Her SVG to PDA is\n patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today following IABP removal\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX for now, will start empirically for HAP or VAP if has leukocytosis\n or CXR findings of infiltrate or fevers\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n - D/c IABP today\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n ICU \n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455194, "text": "Chief Complaint:\n 24 Hour Events:\n - 2 u prbc\n - difficult to confirm IABP placement\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 78 (67 - 80) bpm\n BP: 122/75(90) {94/53(74) - 122/96(102)} mmHg\n RR: 20 (16 - 2,355,555) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 102 mL\n 430 mL\n PO:\n TF:\n IVF:\n 102 mL\n 130 mL\n Blood products:\n 300 mL\n Total out:\n 568 mL\n 81 mL\n Urine:\n 68 mL\n 81 mL\n NG:\n Stool:\n Drains:\n Balance:\n -466 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n SpO2: 98%\n ABG: 7.38/37/151/19/-2\n Ve: 9.6 L/min\n PaO2 / FiO2: 302\n Physical Examination\n Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 255 K/uL\n 9.4 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 114 mEq/L\n 141 mEq/L\n 27.7 %\n 7.5 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n WBC\n 6.9\n 7.5\n Hct\n 23.7\n 27.7\n Plt\n 262\n 255\n Cr\n 0.6\n TropT\n 2.52\n TCO2\n 22\n 23\n Glucose\n 99\n Other labs: PT / PTT / INR:14.0/40.3/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:66/73, Alk Phos / T Bili:119/0.3,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to MI. Currently on IABP and off dopa.\n - wean IABP as tolerated; may need dobutamine\n - heparin gtt with balloon\n - echo\n #. CAD: Severe multivessel disease, now s/p STEMI\n - aspirin 325, plavix 75mg, lipitor 80, heparin ggt\n - check A1c\n - HCT>30\n - consider return to lab\n #. Respiratory: Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX\n #. Normocytic Anemia:. Likely IABP.\n - hapto wnl.\n - goal HCT > 30\n #. FEN: Replete lytes prn\n #. Access: will need to change a-line, CVL in next 24 hours.\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n #. Code: full\n #. Dispo: Pending resolution of above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455200, "text": "Chief Complaint:\n 24 Hour Events:\n - 2 u prbc\n - difficult to confirm IABP placement\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 78 (67 - 80) bpm\n BP: 122/75(90) {94/53(74) - 122/96(102)} mmHg\n RR: 20 (16 - 2,355,555) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 102 mL\n 430 mL\n PO:\n TF:\n IVF:\n 102 mL\n 130 mL\n Blood products:\n 300 mL\n Total out:\n 568 mL\n 81 mL\n Urine:\n 68 mL\n 81 mL\n NG:\n Stool:\n Drains:\n Balance:\n -466 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n SpO2: 98%\n ABG: 7.38/37/151/19/-2\n Ve: 9.6 L/min\n PaO2 / FiO2: 302\n Physical Examination\n Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 255 K/uL\n 9.4 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 114 mEq/L\n 141 mEq/L\n 27.7 %\n 7.5 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n WBC\n 6.9\n 7.5\n Hct\n 23.7\n 27.7\n Plt\n 262\n 255\n Cr\n 0.6\n TropT\n 2.52\n TCO2\n 22\n 23\n Glucose\n 99\n Other labs: PT / PTT / INR:14.0/40.3/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:66/73, Alk Phos / T Bili:119/0.3,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to MI. Currently on IABP and off dopa.\n - wean IABP as tolerated; may need dobutamine for afterload reduction\n - heparin gtt and CXR daily with balloon\n - echo today\n - Check pulses frequently with IABP in place\n #. CAD: Severe multivessel disease, now s/p STEMI\n - aspirin 325, plavix 75mg, lipitor 80, heparin gtt\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs)\n - consider return to lab\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n #. FEN: Replete lytes prn\n #. Access: will need to change a-line, CVL in next 24 hours.\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n #. Code: full\n #. Dispo: Pending resolution of above\n ICU Care\n Nutrition: NPO for now, will need TFs if remains intubated\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2140-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455201, "text": "Chief Complaint:\n 24 Hour Events:\n - 2 u prbc\n - difficult to confirm IABP placement\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 78 (67 - 80) bpm\n BP: 122/75(90) {94/53(74) - 122/96(102)} mmHg\n RR: 20 (16 - 2,355,555) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 102 mL\n 430 mL\n PO:\n TF:\n IVF:\n 102 mL\n 130 mL\n Blood products:\n 300 mL\n Total out:\n 568 mL\n 81 mL\n Urine:\n 68 mL\n 81 mL\n NG:\n Stool:\n Drains:\n Balance:\n -466 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n SpO2: 98%\n ABG: 7.38/37/151/19/-2\n Ve: 9.6 L/min\n PaO2 / FiO2: 302\n Physical Examination\n Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 255 K/uL\n 9.4 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 114 mEq/L\n 141 mEq/L\n 27.7 %\n 7.5 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n WBC\n 6.9\n 7.5\n Hct\n 23.7\n 27.7\n Plt\n 262\n 255\n Cr\n 0.6\n TropT\n 2.52\n TCO2\n 22\n 23\n Glucose\n 99\n Other labs: PT / PTT / INR:14.0/40.3/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:66/73, Alk Phos / T Bili:119/0.3,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to MI. Currently on IABP and off dopa.\n - Will attempt to wean IABP as tolerated following eval of OSH records\n to determine if required for coronary perfusion;\n - may need dobutamine for afterload reduction if decide to wean IABP,\n goal MAP 60, UOP 20cc/hr\n - heparin gtt and CXR daily with balloon\n - echo today to evaluate for progression of wall motion abnormality, to\n eval for anterior wall viability\n - Check pulses frequently with IABP in place\n #. CAD: Severe multivessel disease, now s/p STEMI\n - Continue IABP to increase coronary perfusion\n - Will eval outside hospital cath reports, may need intervention here\n if determine anterior wall has viability\n - aspirin 325, plavix 75mg, lipitor 80, heparin gtt\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs)\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX for now, will start empirically for HAP or VAP if has leukocytosis\n or CXR findings of infiltrate\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n #. FEN: Replete lytes prn\n #. Access: will need to change a-line, CVL in next 24 hours.\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n #. Code: full\n #. Dispo: Pending resolution of above\n ICU Care\n Nutrition: NPO for now, will need TFs if remains intubated\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:30 PM OSH\n Multi Lumen - 08:30 PM OSH\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455189, "text": "Shock, cardiogenic\n Assessment:\n Received pt on IABP 1:1 & on Dopamine 1.5 mcg/k/min. Bilat feet\n initially cool & mottled. Absent Right DP, others dopplerable.\n Oliguric- 10-20cc/hr.\n Action:\n Dopa weaned off. Multiple x-rays to confirm placement on IABP.\n Continues on heparin gtt w/ IABP\n PTT on admit 40.3. Gtt increased to\n 1150 @ 02:15, NO BOLUS per H.O.\n Response:\n HD stable off dopa on 1:1 w/ fair to gd augmentation. Distal perfusion\n improving, Feet warming up, All pedal pulses now dopplerable.\n Plan:\n Confirm IABP placement w/ team\n ? wean IABP today, ? start after load reduction at lose dose\n Monitor R fem, pedal pulses, UOP frequently\n PTT at 08:15.\n Trend cardiac enzymes.\n Anemia, other\n Assessment:\n HCT 23.7 (24 at OSH)\n Action:\n Type & crossed, Blood consented by husband over phone, ordered for 2\n units PRBC over 3hrs w/ 20mg IV lasix after 1^st dose. 1^st unit\n completed @ 06:00. Received lasix at 06:15.\n Response:\n HCT post 1^st transfusion 27.7\n Plan:\n Tranfuse 2^nd unit PRBC, Serial HCTs, goal >30\n Guiac stools\n Pneumonia, other\n Assessment:\n +strep PNA at OSH. Low grade temp 99-100PO overnight. Sm amts thick\n yellow secretions from ETT. Copious amts thin clr oral secretions\n Action:\n Pan cultured\n Response:\n No change\n Plan:\n f/u w/ cultures/CXR, ? abx.\n Suction PRN. Mouth care per VAP protocol.\n NEURO: Opens eyes to voice, sensitive cough & gag. MAE (R leg in leg\n immbolizer). + purposeful mvmts. Easily awakens, agitated w/ mouth\n care, bites down on ETT. Sedation titrated for effect. Not following\n commands. Overbreathing vent 6-10 breaths over. No daily wake up,\n Sedation not turned off to easily agitated for safety of IABP.\n ACCESS: R subclavian placed at OSH, unknown date of placement. Correct\n placement confirmed on CXR. Site appearing WNL. Caps, tubing and dsg\n changed upon admit. Line will need to be changed\n Attempt PIVs today\n GI: NPO, no BM since prior admission to OSH 4/19 per report. Sm\n yellow/mucousy BM on arrival. OGT confirmed placement on CXR. OB+\n stomach aspirates, bilious\n On PPI\n Continue bowel regimen\n ? TF if to remain intubated over weekend (Albumin 2.7).\n Monitor FS QID. Treat as indicated w/ HISS\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455190, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock w/ difficulty weaning from IABP.\n Shock, cardiogenic\n Assessment:\n Received pt on IABP 1:1 & on Dopamine 1.5 mcg/k/min. Bilat feet\n initially cool & mottled. Absent Right DP, others dopplerable.\n Oliguric- 10-20cc/hr.\n Action:\n Dopa weaned off. Multiple x-rays to confirm placement on IABP.\n Continues on heparin gtt w/ IABP\n PTT on admit 40.3. Gtt increased to\n 1150 @ 02:15, NO BOLUS per H.O.\n Response:\n HD stable off dopa on 1:1 w/ fair to gd augmentation. Distal perfusion\n improving, Feet warming up, All pedal pulses now dopplerable.\n Plan:\n Confirm IABP placement w/ team\n ? wean IABP today, ? start after load reduction at lose dose\n Monitor R fem, pedal pulses, UOP frequently\n PTT at 08:15.\n Trend cardiac enzymes, TTE today\n Anemia, other\n Assessment:\n HCT 23.7 (24 at OSH)\n Action:\n Type & crossed, Blood consented by husband over phone, ordered for 2\n units PRBC over 3hrs w/ 20mg IV lasix after 1^st dose. 1^st unit\n completed @ 06:00. Received lasix at 06:15.\n Response:\n HCT post 1^st transfusion 27.7\n Plan:\n Tranfuse 2^nd unit PRBC, Serial HCTs, goal >30\n Guiac stools\n Pneumonia, other\n Assessment:\n +strep PNA at OSH. Low grade temp 99-100PO overnight. Sm amts thick\n yellow secretions from ETT. Copious amts thin clr oral secretions\n Action:\n Pan cultured\n Response:\n No change\n Plan:\n f/u w/ cultures/CXR, ? abx.\n Suction PRN. Mouth care per VAP protocol.\n NEURO: Opens eyes to voice, sensitive cough & gag. MAE (R leg in leg\n immbolizer). + purposeful mvmts. Easily awakens, agitated w/ mouth\n care, bites down on ETT. Sedation titrated for effect. Not following\n commands. Overbreathing vent 6-10 breaths over. No daily wake up,\n Sedation not turned off to easily agitated for safety of IABP.\n ACCESS: R subclavian placed at OSH, unknown date of placement. Correct\n placement confirmed on CXR. Site appearing WNL. Caps, tubing and dsg\n changed upon admit. Line will need to be changed\n Attempt PIVs today\n GI: NPO, no BM since prior admission to OSH 4/19 per report. Sm\n yellow/mucousy BM on arrival. OGT confirmed placement on CXR. OB+\n stomach aspirates, bilious\n On PPI\n Continue bowel regimen\n ? TF if to remain intubated over weekend (Albumin 2.7).\n Monitor FS QID. Treat as indicated w/ HISS\n 07:08\n" }, { "category": "Respiratory ", "chartdate": "2140-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 455295, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: Patient very agitated when awake.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455395, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. \n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo .\n Shock, cardiogenic\n Assessment:\n Received pt on 1:1 with heparin off in anticipation of d/c of\n IABP.hemodynamically stable.\n Action:\n IABP pulled at 9:45am. Started captopril increased to 12.5mg at 1400.\n after IABP pulled sedation weaned in anticipation of extubation. HR and\n BP increased,frothy secretions. Lasix given and NTG drip started.\n Heparin drip restarted at 1630 @ 1600 units/hr\n Response:\n Safely extubated and NTG now weaned off. Great response to lasix.\n Plan:\n Follow hemodynamics and increase captopril as tolerated. Carvedilol to\n be added. Check PTT at 2230.\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2140-05-01 00:00:00.000", "description": "Generic Note", "row_id": 455398, "text": "TITLE:\n Resp Care: Pt received intubated via #7.5 ETT secured 23cm at lip. BS\n clear @apices, decreased @bases. Sx\nd for mod amt thick pale yellow.\n IABP d/c\nd by team in AM. Pt weaned to CPAP in PM. ABG WNL. SBT done,\n pt having ^\nd frothy sputum. Lasix given by nsg. SBT repeated and\n passed. Pt extubated MD and placed on OFM. BS bilat rhonchi, no\n stridor noted. Post-extub ABG pending. Plan: will cont to monitor\n closely.\n 17:13\n" }, { "category": "Physician ", "chartdate": "2140-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455179, "text": "Chief Complaint:\n 24 Hour Events:\n - 2 u prbc\n - difficult to confirm IABP placement\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,150 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 78 (67 - 80) bpm\n BP: 122/75(90) {94/53(74) - 122/96(102)} mmHg\n RR: 20 (16 - 2,355,555) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 102 mL\n 430 mL\n PO:\n TF:\n IVF:\n 102 mL\n 130 mL\n Blood products:\n 300 mL\n Total out:\n 568 mL\n 81 mL\n Urine:\n 68 mL\n 81 mL\n NG:\n Stool:\n Drains:\n Balance:\n -466 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n SpO2: 98%\n ABG: 7.38/37/151/19/-2\n Ve: 9.6 L/min\n PaO2 / FiO2: 302\n Physical Examination\n Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 255 K/uL\n 9.4 g/dL\n 99 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 114 mEq/L\n 141 mEq/L\n 27.7 %\n 7.5 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n WBC\n 6.9\n 7.5\n Hct\n 23.7\n 27.7\n Plt\n 262\n 255\n Cr\n 0.6\n TropT\n 2.52\n TCO2\n 22\n 23\n Glucose\n 99\n Other labs: PT / PTT / INR:14.0/40.3/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:66/73, Alk Phos / T Bili:119/0.3,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:7.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n .\n #. Cardiogenic Shock: to MI. Likely some component of RV infarct\n given echo findings from , severe hypotension, and\n heartblock/bradycardia on presentation. Stable on balloon pump\n currently and low dose pressors. If unable to wean from IABP would\n need to consider transplant or other intervention.\n - wean dopamine as tolerated\n - wean IABP as tolerated\n - follow UOP and goal MAP>60\n - heparin gtt with balloon\n - afterload reduction as tolerated\n - echo in AM\n .\n #. CAD: Severe multivessel disease, now s/p STEMI\n - review OSH cath films\n - aspirin 325\n - plavix 75mg\n - lipitor 80\n - heparin gtt for balloon pump\n - consider return to lab\n - check A1c\n - HCT>30\n .\n #. Respiratory: Intubated.\n - fentanyl/versed for sedation\n .\n #. LE Pulses: dopplerable pulses on arrival. Follow LE pulses closely\n given h/o intermittent loss of pulses at OSH.\n - serial pulse checks\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n #. PVD: Stable\n .\n #. Pneumonia: No h/o fevers, sputum production or focal infiltrate\n - send blood culture/sputum culture\n - CXR\n - hold antibiotics overnight\n .\n #. Anemia: normocytic. Not addressed in OSH records.\n - check ferritin, hapto and LDH\n - guaiac stools\n - type and cross\n - goal HCT > 30\n .\n #. Cocaine Use: Not actively using.\n .\n #. FEN: Replete lytes prn\n .\n #. Access: will need to change a-line, CVL in next 24 hours.\n .\n #. PPx: heparin gtt, bowel regimen prn\n .\n #. Emergency contact:\n .\n #. Code: full\n .\n #. Dispo: Pending resolution of above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455282, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. \n Echo EF 20-25% w/ mildly reduced right ventricular function; mild MR,\n moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Tolerated IABP 1:3, hemodynamically . CVP 13-15. Ptt 56 on 1450units of\n Heparin. U/O trending down.\n Action:\n at 3am switched to 1:1. Heparin adjusted as per orders, off at 3am. u/o\n discussed w/ Dr. \n Response:\n Tolerating IABP 1:1, u/o remains ~20cc/hr\n Plan:\n Plan to d/c IABP cath after am rounds.\n Pneumonia, other\n Assessment:\n LS w/ upper airway ronchi, suctioned for thick whitish secretions. Pt\n biting down on ETT during suctioning. Vent setting remain\n AC/500/14/50%/5. sedated w/ Fentanyl gtt at 100mcg/min and versed gtt\n 3mg/hr.\n Action:\n Additional sedation given for agitation during suctioning\n Response:\n Pt more sedate.\n Plan:\n After IABP d/c\nd and groin stable wean sedation and vent.\n Anemia, other\n Assessment:\n Last Hct 30.3\n Action:\n This am Hct pending\n Response:\n Plan:\n Monitor Hct . Transfuse for a Hct <30\n Altered mental status (not Delirium)\n Assessment:\n Pt on Fentanyl and versed\n Action:\n Provide additional sedation as needed for agitation when suctioned\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455452, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Off IABP since yesterday on days. Poor u/o last evening, reported to\n Drs. and as of 23:00 1900cc neg, reportecd\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2140-05-01 00:00:00.000", "description": "Generic Note", "row_id": 455385, "text": "TITLE:\n Clinical Nutrition\n Tube feed consult received for this 49 y.o. female s/p NSTEMI. Patient\n was just extubated, and MD, there is no plans for tube feeds at\n this time. Will follow up with patient per ICU screening policy.\n Please page with questions #\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455389, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455390, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2140-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 455167, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455168, "text": "Shock, cardiogenic\n Assessment:\n Received pt on IABP 1:1 & on Dopamine 1.5 mcg/k/min. Bilat feet\n initially cool & mottled. Absent Right DP, others dopplerable.\n Oliguric- 10-20cc/hr.\n Action:\n Dopa weaned off. Multiple x-rays to confirm placement on IABP.\n Continues on heparin gtt w/ IABP\n PTT on admit 40.3. Gtt increased to\n 1150 @ 02:15, NO BOLUS per H.O.\n Response:\n HD stable off dopa on 1:1 w/ fair to gd augmentation. IABP in correct\n position per team. Feet warming up, All pedal pulses now dopplerable.\n Plan:\n ? wean IABP today, ? start after load reduction at lose dose\n Monitor R fem, pedal pulses, UOP frequently\n PTT at 08:15.\n Trend cardiac enzymes.\n Anemia, other\n Assessment:\n HCT 23.7 (24 at OSH)\n Action:\n Type & crossed, Blood consented by husband over phone, ordered for 2\n units PRBC over 3hrs w/ 20mg IV lasix after 1^st dose. 1^st unit\n completed @ 06:00. Received lasix at 06:10. 2^nd unit up.\n Response:\n HCT post 1^st transfusion pnd\n Plan:\n Guiac stools\n Serial HCTs, goal >30\n Pneumonia, other\n Assessment:\n +strep PNA at OSH. Low grade temp 99-100PO overnight. Sm amts thick\n yellow secretions from ETT. Copious amts thin clr oral secretions\n Action:\n Pan cultured\n Response:\n No change\n Plan:\n f/u w/ cultures/CXR, ? abx.\n Suction PRN. Mouth care per VAP protocol.\n NEURO: Opens eyes to voice, sensitive cough & gag. MAE (R leg in leg\n immbolizer). + purposeful mvmts. Easily awakens, agitated w/ mouth\n care, bites down on ETT. Sedation titrated for effect. Not following\n commands. Overbreathing vent 6-10 breaths over. No daily wake up,\n Sedation not turned off to easily agitated for safety of IABP.\n ACCESS: R subclavian placed at OSH, unknown date of placement. Correct\n placement confirmed on CXR. Site appearing WNL. Caps, tubing and dsg\n changed upon admit. Line will need to be changed\n Attempt PIVs today\n GI: NPO, no BM since prior admission to OSH 4/19 per report. Sm\n yellow/mucousy BM on arrival. OGT confirmed placement on CXR.\n Continue bowel regimen\n ? TF if to remain intubated over weekend (Albumin 2.7).\n Monitor FS QID. Treat as indicated w/ HISS\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455445, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ; mild\n MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455464, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Off IABP since yesterday on days. Pt started on Coreg for HRin low 100.\n IVNTG wean off , pt started on captopril. Poor u/o (as low\n as10-15cc/hr) last evening, reported to Drs. and . At\n this time pt neg 1900cc and w/ low grade temp 100.3.IV fluid bolus\n ordered.\n Action:\n Fluid bolus given, u/o w/o good response.\n Response:\n 0210 pt tachypneic and w/ labored breathing, sats 97%, bs diminished\n and w/ expir wheezes bilat. Pt restarted on IV NTG, lasix 40mg given\n w/o affect. And started on mask ventilation. Repeat lasix of 80mgs\n given. Pt diuresing for 2^nd dose of Lasix. Potassium replaced last\n evening.\n Plan:\n IV NGT wean off for MAP < 60mmHg.\n Altered mental status (not Delirium)\n Assessment:\n Pt emotional labile, teary then yelling out profanities to saying thank\n you for ice chips. Oriented to self, verbalized that she is in but speech difficult to understand at times. Weak hand grips\n bilaterally. Face symmetrical. Moving legs all over bed and over side\n rail. Attemped to get oob x2\n Action:\n Pt received Zyprexa 5mg x2 w/ less agitated for about an hour.\n Response:\n Pt became agitatied again , in acute delirium received Haldol 2mg x2\n Plan:\n R/o ETOH abuse when speaking to the family . continue falls prevention.\n Pneumonia, other\n Assessment:\n + sputum cultures\n Action:\n Pt remains on Vnco and Zosyn.\n Response:\n Congested cough. Not expectorationg.\n Plan:\n Continue antibiotics, monitor temperature, WBC\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455257, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP.\n Altered mental status (not Delirium)\n Assessment:\n Received on 3mg versed/hr and 75mcg/hr fentanyl. Not obeying commands,\n minimal spontaneous movement\n Action:\n Weaned versed to 2mg/hr and fentanyl to 50mcg/hr\n Response:\n Able to nod head yes or no to questions appropriately. Nodding no when\n asked about oral care. With turn at 4pm became very agitated. Thrashing\n head back and forth, coughing and gagging on ETT,biting down on ETT,\n sats dropped to 80\ns pt turned purplish/blue. SBP jumped up to 160-200.\n received fentanyl and versed boluses of 2mg versed and 75mcg/fentanyl.\n Versed drip increased back to 3mg and fentanyl increased first to 75mcg\n then to 100mcg/hr. required about 45 minutes to return to baseline\n Plan:\n Maintain sedation at current levels. need small boluses prior to\n turning or oral care. consider precidex for sedation prior to\n extubation.\n Anemia, other\n Assessment:\n Repeat HCT after one unit \n Action:\n Transfused second unit packed cells\n Response:\n Repeat HCT 30.3\n Plan:\n Monitor HCT\ns and transfused as needed to maintain HCT>30\n Pneumonia, other\n Assessment:\n Vent on CMV 50% 500 x14 with 5 of peep. Lung sounds rhonchi at 8am.\n Action:\n Suctioned for thick pale yellow secretions small to moderate amounts,\n temp has increased to 100.3po\n Response:\n ABG 7.39/35/102\n Plan:\n Cont to suction as needed,follow temps, ABG\ns and adjust vent as needed\n Shock, cardiogenic\n Assessment:\n Received on IABP 1:1. HR 60-70\ns NSR IABP means 90-100. CVP obtained\n 16-18 heparin drip at 1150 with subtherapeutic PTT. Diuresis after 6am\n lasix . K 3.7\n Action:\n Heparin increased to 1300 units/hr after 1600 unit bolus.Given second\n dose of lasix at 12:30 as urine output trailed off to 10cc/hr. IABP\n changed to 1:2. fluoroscopy at bedside to confirm IABP placement. Had\n cardiac echo K repleted with 40 IV KCL\n Response:\n Repeat PTT 44.9 adequate diuresis after lasix,negative almost 1 liter.\n Hemodynamically stable on 1:2 with good augmentation and unloading.\n IABP in proper postion.repeat K 3.7\n Plan:\n IABP now to 1:4. at 3am heparin off and IABP placed on 1:1 for IABP to\n be pulled before rounds. Cont to follow PTT\ns and titrate heparin .\n monitor CVP and Urine output may need additional lasix has now received\n an additional 40 IV KCL\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455275, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455446, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Off IABP since yesterday on days. Poor u/o last evening\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2140-05-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 455440, "text": "Demographics\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Non-Invasive Positive Pressure Ventilation\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds:Crackles\n LLL Lung Sounds:Crackles\n Ventilation Assessment\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment: Tolerated well\n Comments\n Placed patient on NIV d/t BLBS of crackles, increased WOB,\n diaphoresis. Improved considerably on NIV. Tolerating at this time.\n" }, { "category": "Nursing", "chartdate": "2140-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455584, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Altered mental status (not Delirium)\n Assessment:\n PT SLEEPING ALL DAY NO SEDATION GIVEN SINCE NIGHT SHIFT .RESPONDS TO\n NAME,STATES SHE IS IN THE HOSPITAL.ASKED FOR ICE CREAM,TAKING CL\n LIQUIDS AT PRESENT .HUSBAND VISITING ,SPOKE TO DR\n :\n FOLLOWING NEURO STATUS,MAINTAINING SAFETY\n Response:\n PT NOT TRYING TO GET OOB ,more awake this afternoon,oriented\n andfcooperative\n Plan:\n MAINTAIN SAFETY ,MINIMAL SEDATION\n Shock, cardiogenic\n Assessment:\n PT 2 LITERS ,RALES IN BASES . SAT 97 0N 4L NP .SR 60S,BP\n MARGINAL .PARAMETERS CHANGED ON BP TO 95 ,CARVEDIAL GIVEM BP 80S .WILL\n CHECK BEFORE GIVING ACE.. PERIPHERALS PLACED .R SUCLAVIAN TO BE DC .R\n ARM TENDER AND SWOLLEN THAN L,WARM,PULSES BY DOPPLER. NO BLEEDING\n FROM IABP SITE, old bruise present .DISTAL PULSES BY DOPPLER\n Action:\n MONITOR BP IN RESPONSE TO MEDS.MONITOR FLUID STATUS.PTT 80 ON 1750\n UNITS HEPARIN\n Response:\n STABLE, afternoon k 3.5,k repleted orally, tolerated 2pm Captopril ,2pm\n ptt 95\n Plan:\n CARDIAC MEDS AS TOL ,FOLLOW LYTES ,PTT\n Anemia, other\n Assessment:\n NO EVIDENCE OF BLEEDING\n Action:\n FOLLOW HCT,MONITOR FOR BLEEDING\n Response:\n HCT STABLE 32\n Plan:\n OBSERVE FOR BLEEDING\n Pneumonia, other\n Assessment:\n AFEBRILE,WEAK COUGH ,ANTIBIOTICS CHANGED TO LEVOFLOXIN\n Action:\n ENCOURAGE TCDB,MAINTAIN O2 SAT\n Response:\n STABLE\n Plan:\n WEAN O2,FOLLOW TEMP ANTIBIOTICS AS TOL\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455244, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2140-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455340, "text": "Chief Complaint:\n 24 Hour Events:\n :\n - Weaned FiO2 to 40%\n - Started TFs and consulted nutrition\n - Attempted to wean sedation, however patient very agitated\n - Gave 20mg of IV lasix at 12:30\n - Able to wean IABP to 1:2 without need of pressors, on 1:4 overnight\n without problem, plan to stop heparin at 3am and put back at 1:1 in\n anticipation of discontinuing\n - Hct 30 at 2:30pm\n - Confirmed placement of IABP with fluroscopy\n - Planned to resite line, however as pt not tolerating manipulation and\n likely patient will not need triple lumen for more than 24 hours, will\n plan on keeping subclavian and attempt to place PIV\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.7\n HR: 77 (63 - 87) bpm\n BP: 115/72(92) {78/35(58) - 128/97(100)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (8 - 294)mmHg\n Total In:\n 1,421 mL\n 120 mL\n PO:\n TF:\n IVF:\n 751 mL\n 120 mL\n Blood products:\n 610 mL\n Total out:\n 2,227 mL\n 85 mL\n Urine:\n 2,227 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n -806 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 580 (580 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 53\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/39/95./20/-2\n Ve: 9.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Gen: in NAD. Intubated and sedated\n HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis\n of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Balloon pump\n in place\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 331 K/uL\n 11.3 g/dL\n 83 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 110 mEq/L\n 141 mEq/L\n 33.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n 02:23 PM\n 02:40 PM\n 05:26 PM\n 04:26 AM\n 04:44 AM\n WBC\n 6.9\n 7.5\n 8.7\n Hct\n 23.7\n 27.7\n 30.3\n 33.0\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n TropT\n 2.52\n TCO2\n 22\n 23\n 24\n 22\n 23\n Glucose\n 99\n 97\n 83\n Other labs: PT / PTT / INR:13.7/38.8/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Imaging: TTE: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. LV\n systolic function is depressed (ejection fraction 40-50 percent)\n secondary to extensive severe apical akinesis with focal dyskinesis.\n The anterior septum and anterior free wall are severely\n hypokinetic/akinetic. The rest of the left ventricle is hyperdynamic.\n Tissue Doppler imaging suggests an increased left ventricular filling\n pressure (PCWP>18mmHg). There is no ventricular septal defect. Right\n ventricular chamber size is normal. with borderline normal free wall\n function. [Intrinsic right ventricular systolic function is likely more\n depressed given the severity of tricuspid regurgitation.] The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve appears\n structurally normal with trivial mitral regurgitation. Moderate [2+]\n tricuspid regurgitation is seen. However, due to extensive acoustic\n artifact from the right heart wire/catheter, the amount of tricuspid\n regurgitation may be inaccurately quantitated by color-flow imaging.\n There is moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n Compared with the findings of the prior report (images unavailable for\n review) of , extensive left ventricular contractile\n dysfunction now present. A wire/catheter is seen crossing the tricuspid\n valve, and there is now significant tricuspid regurgitation, possibly\n related to the wire/catheter.\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to large acute anterior myocardial\n infarction. Currently on IABP with plan to wean to pull this AM\n - As IABP is not required for coronary perfusion and blood pressures\n stable on 1:4, will pull this AM\n - unlikely to require dobutamine for afterload reducing as pressures\n remained stable on 1:4\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n - Check pulses frequently with IABP in place but will be d/c\nd today\n .\n #. CAD: Severe multivessel disease, now s/p STEMI acute anterior wall,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Otherwise her mid LAD is occluded and\n there is a proximal LAD stenosis that supplies a moderate size\n diagonal, that on cath film appears to supply a viable, contracting\n territory. Her SVG to OM has in stent restenosis. Her SVG to PDA is\n patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today following IABP removal\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX for now, will start empirically for HAP or VAP if has leukocytosis\n or CXR findings of infiltrate or fevers\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n - D/c IABP today\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n ICU \n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2140-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455341, "text": "Chief Complaint:\n 24 Hour Events:\n :\n - Weaned FiO2 to 40%\n - Started TFs and consulted nutrition\n - Attempted to wean sedation, however patient very agitated\n - Gave 20mg of IV lasix at 12:30\n - Able to wean IABP to 1:2 without need of pressors, on 1:4 overnight\n without problem, plan to stop heparin at 3am and put back at 1:1 in\n anticipation of discontinuing\n - Hct 30 at 2:30pm\n - Confirmed placement of IABP with fluroscopy\n - Planned to resite line, however as pt not tolerating manipulation and\n likely patient will not need triple lumen for more than 24 hours, will\n plan on keeping subclavian and attempt to place PIV\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.7\n HR: 77 (63 - 87) bpm\n BP: 115/72(92) {78/35(58) - 128/97(100)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (8 - 294)mmHg\n Total In:\n 1,421 mL\n 120 mL\n PO:\n TF:\n IVF:\n 751 mL\n 120 mL\n Blood products:\n 610 mL\n Total out:\n 2,227 mL\n 85 mL\n Urine:\n 2,227 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n -806 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 580 (580 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 53\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/39/95./20/-2\n Ve: 9.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Gen: in NAD. Intubated and sedated\n HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis\n of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Balloon pump\n in place\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 331 K/uL\n 11.3 g/dL\n 83 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 110 mEq/L\n 141 mEq/L\n 33.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n 02:23 PM\n 02:40 PM\n 05:26 PM\n 04:26 AM\n 04:44 AM\n WBC\n 6.9\n 7.5\n 8.7\n Hct\n 23.7\n 27.7\n 30.3\n 33.0\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n TropT\n 2.52\n TCO2\n 22\n 23\n 24\n 22\n 23\n Glucose\n 99\n 97\n 83\n Other labs: PT / PTT / INR:13.7/38.8/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Imaging: TTE: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. LV\n systolic function is depressed (ejection fraction 40-50 percent)\n secondary to extensive severe apical akinesis with focal dyskinesis.\n The anterior septum and anterior free wall are severely\n hypokinetic/akinetic. The rest of the left ventricle is hyperdynamic.\n Tissue Doppler imaging suggests an increased left ventricular filling\n pressure (PCWP>18mmHg). There is no ventricular septal defect. Right\n ventricular chamber size is normal. with borderline normal free wall\n function. [Intrinsic right ventricular systolic function is likely more\n depressed given the severity of tricuspid regurgitation.] The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve appears\n structurally normal with trivial mitral regurgitation. Moderate [2+]\n tricuspid regurgitation is seen. However, due to extensive acoustic\n artifact from the right heart wire/catheter, the amount of tricuspid\n regurgitation may be inaccurately quantitated by color-flow imaging.\n There is moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n Compared with the findings of the prior report (images unavailable for\n review) of , extensive left ventricular contractile\n dysfunction now present. A wire/catheter is seen crossing the tricuspid\n valve, and there is now significant tricuspid regurgitation, possibly\n related to the wire/catheter.\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to large acute anterior myocardial\n infarction. Currently on IABP with plan to wean to pull this AM\n - As IABP is not required for coronary perfusion and blood pressures\n stable on 1:4, will pull this AM\n - unlikely to require dobutamine for afterload reducing as pressures\n remained stable on 1:4\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n - Check pulses frequently with IABP in place but will be d/c\nd today\n .\n #. CAD: Severe multivessel disease, now s/p STEMI acute anterior wall,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Otherwise her mid LAD is occluded and\n there is a proximal LAD stenosis that supplies a moderate size\n diagonal, that on cath film appears to supply a viable, contracting\n territory. Her SVG to OM has in stent restenosis. Her SVG to PDA is\n patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today following IABP removal\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX for now, will start empirically for HAP or VAP if has leukocytosis\n or CXR findings of infiltrate or fevers\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n - D/c IABP today\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n ICU \n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am for IABP pulling today\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ------ Protected Section ------\n Chart reviewed. Patient examined on CCU Rounds. Unable to interview\n due to intubation. I agree with Dr. \ns H+P, A+P. Plan for\n IABP d/c today with initiation of pharmacologic afterload reduction.\n Possible addition of betablocker if tolerated. 60 minutes spent on\n patient critical care. ICU level care secondary to intubation and\n IABP.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:25 ------\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455250, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP.\n Altered mental status (not Delirium)\n Assessment:\n Received on 3mg versed/hr and 75mcg/hr fentanyl. Not obeying commands,\n minimal spontaneous movement\n Action:\n Weaned versed to 2mg/hr and fentanyl to 50mcg/hr\n Response:\n Able to nod head yes or no to questions appropriately. Nodding no when\n asked about oral care. With turn at 4pm became very agitated. Thrashing\n head back and forth, coughing and gagging on ETT,biting down on ETT,\n sats dropped to 80\ns pt turned purplish/blue. SBP jumped up to 160-200.\n received fentanyl and versed boluses of 2mg versed and 75mcg/fentanyl.\n Versed drip increased back to 3mg and fentanyl increased first to 75mcg\n then to 100mcg/hr. required about 45 minutes to return to baseline\n Plan:\n Maintain sedation at current levels. need small boluses prior to\n turning or oral care. consider precidex for sedation prior to\n extubation.\n Anemia, other\n Assessment:\n Repeat HCT after one unit \n Action:\n Transfused second unit packed cells\n Response:\n Repeat HCT 30.3\n Plan:\n Monitor HCT\ns and transfused as needed to maintain HCT>30\n Pneumonia, other\n Assessment:\n Vent on CMV 50% 500 x14 with 5 of peep. Lung sounds rhonchi at 8am.\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Received on IABP 1:1. HR 60-70\ns NSR IABP means 90-100. CVP obtained\n 16-18 heparin drip at 1150 with subtherapeutic PTT. Diuresis after 6am\n lasix .\n Action:\n Heparin increased to 1300 units/hr after 1600 unit bolus.Given second\n dose of lasix at 12:30 as urine output trailed off to 10cc/hr. IABP\n changed to 1:2.\n Response:\n Repeat PTT 44.9 adequate diuresis after lasix,negative almost 1 liter.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455253, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP.\n Altered mental status (not Delirium)\n Assessment:\n Received on 3mg versed/hr and 75mcg/hr fentanyl. Not obeying commands,\n minimal spontaneous movement\n Action:\n Weaned versed to 2mg/hr and fentanyl to 50mcg/hr\n Response:\n Able to nod head yes or no to questions appropriately. Nodding no when\n asked about oral care. With turn at 4pm became very agitated. Thrashing\n head back and forth, coughing and gagging on ETT,biting down on ETT,\n sats dropped to 80\ns pt turned purplish/blue. SBP jumped up to 160-200.\n received fentanyl and versed boluses of 2mg versed and 75mcg/fentanyl.\n Versed drip increased back to 3mg and fentanyl increased first to 75mcg\n then to 100mcg/hr. required about 45 minutes to return to baseline\n Plan:\n Maintain sedation at current levels. need small boluses prior to\n turning or oral care. consider precidex for sedation prior to\n extubation.\n Anemia, other\n Assessment:\n Repeat HCT after one unit \n Action:\n Transfused second unit packed cells\n Response:\n Repeat HCT 30.3\n Plan:\n Monitor HCT\ns and transfused as needed to maintain HCT>30\n Pneumonia, other\n Assessment:\n Vent on CMV 50% 500 x14 with 5 of peep. Lung sounds rhonchi at 8am.\n Action:\n Suctioned for thick pale yellow secretions small to moderate amounts,\n temp has increased to 100.3po\n Response:\n ABG 7.39/35/102\n Plan:\n Cont to suction as needed,follow temps, ABG\ns and adjust vent as needed\n Shock, cardiogenic\n Assessment:\n Received on IABP 1:1. HR 60-70\ns NSR IABP means 90-100. CVP obtained\n 16-18 heparin drip at 1150 with subtherapeutic PTT. Diuresis after 6am\n lasix . K 3.7\n Action:\n Heparin increased to 1300 units/hr after 1600 unit bolus.Given second\n dose of lasix at 12:30 as urine output trailed off to 10cc/hr. IABP\n changed to 1:2. fluoroscopy at bedside to confirm IABP placement. Had\n cardiac echo K repleted with 40 IV KCL\n Response:\n Repeat PTT 44.9 adequate diuresis after lasix,negative almost 1 liter.\n Hemodynamically stable on 1:2 with good augmentation and unloading.\n IABP in proper postion.repeat K 3.7\n Plan:\n IABP now to 1:4. at 3am heparin off and IABP placed on 1:1 for IABP to\n be pulled before rounds. Cont to follow PTT\ns and titrate heparin .\n monitor CVP and Urine output may need additional lasix has now received\n an additional 40 IV KCL\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455637, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n BPs 90-one teens/60-70s, HR 70-80s SR. UOP trending down 15-30cc/hr\n Action:\n 12.5mg Captopril and 3.125 Coreg given as ordered. 80mg IV lasix given\n at 22:00. Heparin gtt for apical AK therapeutic\n Response:\n HD stable, tolerated cardiac meds. Good response to lasix, Diuresed ~2L\n in 4 hrs\n Plan:\n Continue cardiac meds, hold per BP parameters\n ? adding standing dose PO lasix, replete lytes as indicated.\n GOAL -1L/day\n Past smoker, quit 6 wks ago\n continue to encourage and\n support smoking cessation\n Viability study prior to Discharge\n Daily Coags, ? start coumadin\n Pneumonia, other\n Assessment:\n Afebrile, WBC flat, productive cough. Sats >95% w/ supplemental 02 2L.\n Denies SOB/DOE\n Plan:\n Levofloxacin x4 more days\n Encourage C&DB, wean 02\n ^ activity as tol, get OOB, PT c/s\n Anemia, other\n Assessment:\n No evidence bleeding (liq stool, guiac neg)\n Plan:\n Continue to monitor s/sx bleeding, goal HCT >30\n Altered mental status (not Delirium)\n Assessment:\n Pleasant and cooperative, A&Ox3. Speaking to relatives on phone.\n Difficult falling asleep. Requested sleep aid\n Action:\n 5mg ambient given. Safety/fall precautions maintained, pt encouraged to\n use call light for assistance prior to getting OOB to commode.\n Response:\n Slept well after\n Plan:\n Continue fall/safety precautions, re-orient PRN\n Provide calm environment, increase stimulation during the\n day to promote rest/sleep at night.\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455699, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs: PT / PTT / INR:16.9/82.3/1.5, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:9.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455700, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. ;\n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo . mild MR, moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Altered mental status (not Delirium)\n Assessment:\n PT SLEEPING ALL DAY NO SEDATION GIVEN SINCE NIGHT SHIFT .RESPONDS TO\n NAME,STATES SHE IS IN THE HOSPITAL.ASKED FOR ICE CREAM,TAKING CL\n LIQUIDS AT PRESENT .HUSBAND VISITING ,SPOKE TO DR\n :\n FOLLOWING NEURO STATUS,MAINTAINING SAFETY\n Response:\n PT NOT TRYING TO GET OOB ,more awake this afternoon,oriented\n andfcooperative\n Plan:\n MAINTAIN SAFETY ,MINIMAL SEDATION\n Shock, cardiogenic\n Assessment:\n PT 2 LITERS ,RALES IN BASES . SAT 97 0N 4L NP .SR 60S,BP\n MARGINAL .PARAMETERS CHANGED ON BP TO 95 ,CARVEDIAL GIVEM BP 80S .WILL\n CHECK BEFORE GIVING ACE.. PERIPHERALS PLACED .R SUCLAVIAN TO BE DC .R\n ARM TENDER AND SWOLLEN THAN L,WARM,PULSES BY DOPPLER. NO BLEEDING\n FROM IABP SITE, old bruise present .DISTAL PULSES BY DOPPLER\n Action:\n MONITOR BP IN RESPONSE TO MEDS.MONITOR FLUID STATUS.PTT 80 ON 1750\n UNITS HEPARIN\n Response:\n STABLE, afternoon k 3.5,k repleted orally, tolerated 2pm Captopril ,2pm\n ptt 95\n Plan:\n CARDIAC MEDS AS TOL ,FOLLOW LYTES ,PTT\n Anemia, other\n Assessment:\n NO EVIDENCE OF BLEEDING\n Action:\n FOLLOW HCT,MONITOR FOR BLEEDING\n Response:\n HCT STABLE 32\n Plan:\n OBSERVE FOR BLEEDING\n Pneumonia, other\n Assessment:\n AFEBRILE,WEAK COUGH ,ANTIBIOTICS CHANGED TO LEVOFLOXIN\n Action:\n ENCOURAGE TCDB,MAINTAIN O2 SAT\n Response:\n STABLE\n Plan:\n WEAN O2,FOLLOW TEMP ANTIBIOTICS AS TOL\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455705, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs:\n PT / PTT / INR:16.9/82.3/1.5,\n Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n CXR \n There is interval slight progression of the opacification of both lung\n bases that might be consistent with aspiration versus the\n underdevelopment of infectious process. Bilateral pleural effusions are\n most likely present, small-to-moderate. No evidence of overt pulmonary\n edema is seen. The patient is in mild interstitial engorgement. The\n right subclavian line tip is in mid SVC. No pneumothorax is present.\n Bilateral stents in the most likely\n subclavian and brachiocephalic arteries are present .\n MICRO:\n sputum from \n oropharengeal flora.\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n - cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would provide benefit at this time\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2, day #4 of antibiotics.\n - discontinue vanc and zosyn for now\n - start levofloxacin 750mg x 5 days\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today and place PICC\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines:\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455706, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs:\n PT / PTT / INR:16.9/82.3/1.5,\n Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n CXR \n There is interval slight progression of the opacification of both lung\n bases that might be consistent with aspiration versus the\n underdevelopment of infectious process. Bilateral pleural effusions are\n most likely present, small-to-moderate. No evidence of overt pulmonary\n edema is seen. The patient is in mild interstitial engorgement. The\n right subclavian line tip is in mid SVC. No pneumothorax is present.\n Bilateral stents in the most likely\n subclavian and brachiocephalic arteries are present .\n MICRO:\n sputum from \n oropharengeal flora.\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n - cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would provide benefit at this time\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2, day #4 of antibiotics.\n - discontinue vanc and zosyn for now\n - start levofloxacin 750mg x 5 days\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today and place PICC\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines:\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455707, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: tr pedal edema\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs:\n PT / PTT / INR:16.9/82.3/1.5,\n Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n CXR \n There is interval slight progression of the opacification of both lung\n bases that might be consistent with aspiration versus the\n underdevelopment of infectious process. Bilateral pleural effusions are\n most likely present, small-to-moderate. No evidence of overt pulmonary\n edema is seen. The patient is in mild interstitial engorgement. The\n right subclavian line tip is in mid SVC. No pneumothorax is present.\n Bilateral stents in the most likely\n subclavian and brachiocephalic arteries are present .\n MICRO:\n sputum from \n oropharengeal flora.\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n - cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for IABP being held currently for pulling IABP and will\n restart after for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Mid LAD is occluded and there is a\n proximal LAD stenosis that supplies a moderate size diagonal, that on\n cath film appears to supply a viable, contracting territory. Her SVG\n to OM has in stent restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would provide benefit at this time\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling), start captopril today and consider\n coreg later if BPs ok after captopril\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs). Will check\n hct later today to ensure stable\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2, day #4 of antibiotics.\n - discontinue vanc and zosyn for now\n - start levofloxacin 750mg x 5 days\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today and place PICC\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines:\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2140-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 455243, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time); Comments: s/p MI\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: dissynchronous when sedation lightened by nsg.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: synchronous except when sedation lightened by nsg.\n Plan\n Next 24-48 hours: Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability; Comments: IABP in place.\n Respiratory Care Shift Procedures\n 17:50\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455418, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated with IABP and dopa Echo EF\n 40-50%, 2+ TR w/ extensive left ventricle contractile dysfunction\n compared to echo .\n Shock, cardiogenic\n Assessment:\n Received pt on 1:1 with heparin off in anticipation of d/c of\n IABP.hemodynamically stable.\n Action:\n IABP pulled at 9:45am. Started captopril increased to 12.5mg at 1400.\n after IABP pulled sedation weaned in anticipation of extubation. HR and\n BP increased,frothy secretions. Lasix given and NTG drip started.\n Heparin drip restarted at 1630 @ 1600 units/hr\n Response:\n Safely extubated . Great response to lasix.\n Plan:\n Follow hemodynamics and increase captopril as tolerated. Carvedilol to\n be added. Check PTT at 2230.\n Pneumonia, other\n Assessment:\n Intubated on CMV 50% 500 x14. sputum culture from gram + cocci\n prs and clusters. Tmax 100 po\n Action:\n IV abx started: Zosyn and vanco. After IABP d/ced weaned vent to PSV\n 10 then 5.sedation also weaned. first attempt at SBT increase in frothy\n secretions given lasix. Extubated about 1600.\n Response:\n ABG\ns post extubation on 50% face tent-87-76/ 24-25/7.49 rr 20-28 has\n productive cough.\n Plan:\n Team notified regarding ABG\ns. ? CXRAY may need more diuresis\n Altered mental status (not Delirium)\n Assessment:\n Easily agitated while weaning sedation, not obeying commands but\n nodding head appropriately.\n Action:\n Sedation weaned to off and extubated\n Response:\n Now oriented x1-2 immediately post extubation went from crying to\n laughing several times. Remains intermittingly drowsy and restless. Can\n answer questions appropriately regarding her family.\n Plan:\n Closely monitor. Bed in low position and alarm on. Team aware. Reorient\n frequently. Emotional support.\n" }, { "category": "Nursing", "chartdate": "2140-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 455719, "text": "49 y/o F w/ significant cardiac hx, transferred from OSH w/\n unrevascularized STEMI (occluded SVG-LAD) & cardiogenic shock,\n intubated w/ difficulty weaning from IABP. TTE EF 40-50%, WMA\n c/w Lg ant MI, anterior septal & free wall HK/AK, 2+ TR. S/p\n transfusion 2 units PRBC for HCT 23.7 on admission. On abx for GPC\n in sputum. IABP removed & extubated . Acute delirium f/b acute pulm\n edema post extubation requiring NGT gtt, lasix, Morphine, haldol &\n brief mask ventilation.\n" }, { "category": "Physician ", "chartdate": "2140-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455723, "text": "Chief Complaint:\n 24 Hour Events:\n -put out 3200 cc to 120 mg IV lasix given 0200 (-1600)\n -gave another 80 mg IV @ 2130\n -changed vanc/zosyn -> levo 750 x 5 days for PNA\n -2 PIV placed, R subclav pulled\n -advanced diet to reg\n -dr. requested viability study p/t graft revasc\n S: pt reports new diarrhea (4BM/24hrs) after eating normal meals for\n the first time yesterday. Tolerating POs. No n/v or abdominal pain.\n No CP/SOB/F/C.\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Vancomycin - 01:01 AM\n Piperacillin - 04:22 AM\n Infusions:\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:20 AM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 69 (64 - 88) bpm\n BP: 98/66(74) {86/60(64) - 124/97(102)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 16 (0 - 16)mmHg\n Total In:\n 1,733 mL\n 240 mL\n PO:\n 780 mL\n 120 mL\n TF:\n IVF:\n 953 mL\n 120 mL\n Blood products:\n Total out:\n 3,848 mL\n 1,585 mL\n Urine:\n 3,748 mL\n 1,585 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -2,115 mL\n -1,345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: Awake, alert, NAD\n HEENT: anicteric, conjunctiva pink, dry MM\n NECK: neck veins flat @ HOB 30 deg\n CV: reg rate nl S1S2 no m/r/g\n Pulm: R basilar crackles, no wheeze/rhonchi\n Abd: soft NTND NABS\n Ext: wwp. trace pedal edema. Pulses +dop PT and DP bilat\n Neuro: A&Ox3.\n Labs / Radiology\n 481 K/uL\n 13.2 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 101 mEq/L\n 141 mEq/L\n 37.5 %\n 8.6 K/uL\n [image002.jpg]\n 01:41 PM\n 01:58 PM\n 03:12 PM\n 05:23 PM\n 06:26 PM\n 10:08 PM\n 02:35 AM\n 04:05 AM\n 02:13 PM\n 04:15 AM\n WBC\n 8.1\n 8.6\n Hct\n 31.5\n 32.9\n 37.5\n Plt\n 408\n 481\n Cr\n 0.8\n 0.8\n 0.8\n 1.0\n TCO2\n 23\n 24\n 19\n 20\n 24\n Glucose\n 101\n 98\n 96\n Other labs:\n PT / PTT / INR:16.9/82.3/1.5,\n Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:5.5 mg/dL\n CXR \n There is interval slight progression of the opacification of both lung\n bases that might be consistent with aspiration versus the\n underdevelopment of infectious process. Bilateral pleural effusions are\n most likely present, small-to-moderate. No evidence of overt pulmonary\n edema is seen. The patient is in mild interstitial engorgement. The\n right subclavian line tip is in mid SVC. No pneumothorax is present.\n Bilateral stents in the most likely\n subclavian and brachiocephalic arteries are present .\n MICRO:\n sputum from \n oropharengeal flora.\n Assessment and Plan\n 49 y/o F w/ CAD s/p CABG, prior VF arrest p/w unrevascularized anterior\n STEMI and cardiogenic shock s/p removal of IABP and extubation .\n .\n #Cardiogenic Shock\n resolved, hemodynamically stable s/p extubation\n and IABP removal\n - cont captopril and carvedilol for afterload reduction (change hold\n parameters to SBP 90)\n - heparin gtt for apical AK on TTE as bridge to coumadin\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR. Will need coumadin prior to d/c\n for apical AK.\n .\n #. CAD: Severe multivessel disease, now s/p anterior wall STEMI, likely\n secondary to SSVG to LAD occlusion based on OSH cath images on\n review. Mid LAD is occluded and there is a proximal LAD stenosis that\n supplies a moderate size diagonal, that on cath film appears to supply\n a viable, contracting territory. Her SVG to OM has in stent\n restenosis. Her SVG to PDA is patent.\n - Unlikely repeat PCI would provide benefit at this time\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt\n - cont captopril & coreg\n - hbA1c is 5.7\n - transfuse to HCT<30 (s/p transfusion of 2 units of PRBCs).\n .\n #. Respiratory failure: Secondary to cardiogenic shock, extubated.\n Flashed yesterday and responded well to lasix bolus with improvement in\n clinical parameters\n - wean O2 as tolerated\n - no need for lasix currently, monitor UOP to keep negative 1L\n .\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n .\n # Pneumonia\n low grade temp O/N, sputum gram stain w/ GPC\n pairs/clusters but Cx mod growth OP flora; has been on vent for\n extended period however. Unlikely MRSA pneumonia. Not hospital\n acquired. Has defervesced and improved clinically. Currently on\n Vanc/Zosyn day #2, day #4 of antibiotics.\n - discontinue vanc and zosyn for now\n - start levofloxacin 750mg x 5 days\n .\n #. Normocytic Anemia\n presumed IABP placement, hapto wnl, s/p 2 U\n PRBC\n -maintain Hct > 30\n .\n #. Access: will need to d/c OSH lines today and place PICC\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n .\n ICU Care\n Nutrition: clears then ADAT\n Glycemic Control:\n Lines:\n 18 Gauge - 01:14 PM\n 20 Gauge - 01:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 455310, "text": "Chief Complaint:\n 24 Hour Events:\n :\n - Weaned FiO2 to 40%\n - Started TFs and consulted nutrition\n - Attempted to wean sedation, however patient very agitated\n - Gave 20mg of IV lasix at 12:30\n - Able to wean IABP to 1:2 without need of pressors, on 1:4 overnight\n without problem, plan to stop heparin at 3am and put back at 1:1 in\n anticipation of discontinuing\n - Hct 30 at 2:30pm\n - Confirmed placement of IABP with fluroscopy\n - Planned to resite line, however as pt not tolerating manipulation and\n likely patient will not need triple lumen for more than 24 hours, will\n plan on keeping subclavian and attempt to place PIV\n Allergies:\n Codeine\n Hives; Nausea/V\n Hydrocodone\n Nausea/Vomiting\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.7\n HR: 77 (63 - 87) bpm\n BP: 115/72(92) {78/35(58) - 128/97(100)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (8 - 294)mmHg\n Total In:\n 1,421 mL\n 120 mL\n PO:\n TF:\n IVF:\n 751 mL\n 120 mL\n Blood products:\n 610 mL\n Total out:\n 2,227 mL\n 85 mL\n Urine:\n 2,227 mL\n 85 mL\n NG:\n Stool:\n Drains:\n Balance:\n -806 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 580 (580 - 580) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 53\n PIP: 10 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/39/95./20/-2\n Ve: 9.3 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Gen: in NAD. Intubated and sedated\n HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis\n of the oral mucosa. No xanthalesma.\n Neck: Supple with JVP of 8 cm.\n CV: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Balloon pump\n in place\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n Ext: No c/c/e. No femoral bruits.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 331 K/uL\n 11.3 g/dL\n 83 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 110 mEq/L\n 141 mEq/L\n 33.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:20 PM\n 09:40 PM\n 06:01 AM\n 06:14 AM\n 02:23 PM\n 02:40 PM\n 05:26 PM\n 04:26 AM\n 04:44 AM\n WBC\n 6.9\n 7.5\n 8.7\n Hct\n 23.7\n 27.7\n 30.3\n 33.0\n Plt\n \n Cr\n 0.6\n 0.7\n 0.7\n TropT\n 2.52\n TCO2\n 22\n 23\n 24\n 22\n 23\n Glucose\n 99\n 97\n 83\n Other labs: PT / PTT / INR:13.7/38.8/1.2, CK / CKMB /\n Troponin-T:760/7/2.52, ALT / AST:64/72, Alk Phos / T Bili:128/0.4,\n Differential-Neuts:75.8 %, Lymph:18.1 %, Mono:2.5 %, Eos:3.1 %, Lactic\n Acid:0.7 mmol/L, Albumin:2.7 g/dL, LDH:587 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Imaging: TTE: The left atrium is normal in size. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. LV\n systolic function is depressed (ejection fraction 40-50 percent)\n secondary to extensive severe apical akinesis with focal dyskinesis.\n The anterior septum and anterior free wall are severely\n hypokinetic/akinetic. The rest of the left ventricle is hyperdynamic.\n Tissue Doppler imaging suggests an increased left ventricular filling\n pressure (PCWP>18mmHg). There is no ventricular septal defect. Right\n ventricular chamber size is normal. with borderline normal free wall\n function. [Intrinsic right ventricular systolic function is likely more\n depressed given the severity of tricuspid regurgitation.] The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve appears\n structurally normal with trivial mitral regurgitation. Moderate [2+]\n tricuspid regurgitation is seen. However, due to extensive acoustic\n artifact from the right heart wire/catheter, the amount of tricuspid\n regurgitation may be inaccurately quantitated by color-flow imaging.\n There is moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n Compared with the findings of the prior report (images unavailable for\n review) of , extensive left ventricular contractile\n dysfunction now present. A wire/catheter is seen crossing the tricuspid\n valve, and there is now significant tricuspid regurgitation, possibly\n related to the wire/catheter.\n Assessment and Plan\n Patient is a 49 y/o F w/ h/o CAD s/p CABG, prior VF arrest who p/w\n unrevascularized STEMI and cardiogenic shock with diffuclty weaning\n from IABP and pressors.\n #. Cardiogenic Shock: to large acute anterior myocardial\n infarction. Currently on IABP with plan to wean to pull this AM\n - As IABP is not required for coronary perfusion and blood pressures\n stable on 1:4, will pull this AM\n - unlikely to require dobutamine for afterload reducing as pressures\n remained stable on 1:4\n - heparin gtt for IABP\n - TTE showed WMA consistent with large anterior MI, anterior septum and\n free wall hypokinetic/ akinetic, and EF depressed to 40-50%, question\n if ICD line is causing worsening TR\n - Check pulses frequently with IABP in place\n .\n #. CAD: Severe multivessel disease, now s/p STEMI acute anterior wall,\n several days old, likely secondary to SSVG to LAD occlusion based on\n OSH cath images on review. Otherwise her mid LAD is occluded and\n there is a proximal LAD stenosis that supplies a moderate size\n diagonal, that on cath film appears to supply a viable, contracting\n territory. Her SVG to OM has in stent restenosis. Her SVG to PDA is\n patent.\n - Unlikely repeat PCI would benefit at this time\n - No significant tight proximal lesions that would benefit from IABP,\n will dc today\n - Will eventually need viability study prior to discharge\n - continue aspirin 325, plavix 75mg, lipitor 80, heparin gtt (stopped\n at 3am in prep for IABP pulling)\n - check A1c\n - transfuse to HCT>30 (s/p transfusion of 2 units of PRBCs)\n #. Respiratory failure: Secondary to cardiogenic shock, Intubated.\n - fentanyl/versed for sedation\n - wean sedation and attempt RISBI later today following IABP removal\n # Transaminitis: Presumably ischemic, trend enzymes and consider\n further w/u PRN\n # Pneumonia:. afebrile overnight, WBCs stable, CXR c/w edema. Holding\n ABX for now, will start empirically for HAP or VAP if has leukocytosis\n or CXR findings of infiltrate\n #. Normocytic Anemia:. Likely IABP related.\n - hapto wnl.\n - s/p transfusion of 2 units of PRBCs\n - goal HCT > 30\n #. Access: will need to d/c OSH lines today likely will not require CVL\n following IABP removal and extubation\n #. PPx: heparin gtt, bowel regimen prn\n #. Emergency contact:\n ICU \n Nutrition: Tube feeds going, will have to stop if plan to extubate\n Glycemic Control:\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n IABP line - 08:30 PM\n Prophylaxis:\n DVT: Heparin gtt until 3am\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455315, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. \n Echo EF 20-25% w/ mildly reduced right ventricular function; mild MR,\n moderate to severe TR.\n Hx: CABG x5 sequential SVG to LAD to diagonal, sequential SVG to\n RPDA to Posterolaterl branch, and SVG to OM.\n Echo EF 60%\n 100% occlusion of SVG to LAD, 80% in-stent restenosis of the SVG to OM.\n Mild MR, Mod to severe TR.\n PVD, s/p bilateral subclavian stenting, carotid bruit.\n Arrythmia: possible cocaine-induced cardiomyopathy, s/p VF arrest, sp\n ICD.\n HTN, Hyperlipidemia Tobacco abuse, GERD, s/p tubal ligation\n Shock, cardiogenic\n Assessment:\n Tolerated IABP 1:3, hemodynamically . CVP 13-15. Ptt 56 on 1450units of\n Heparin. U/O trending down.\n Action:\n at 3am switched to 1:1. Heparin adjusted as per orders, off at 3am. u/o\n discussed w/ Dr. \n Response:\n Tolerating IABP 1:1, u/o remains ~20cc/hr or less\n Plan:\n Plan to d/c IABP cath after am rounds. Potassium replacement.\n Pneumonia, other\n Assessment:\n LS w/ upper airway ronchi, suctioned for thick whitish secretions. Pt\n biting down on ETT during suctioning. Vent setting remain\n AC/500/14/50%/5. sedated w/ Fentanyl gtt at 100mcg/min and versed gtt\n 3mg/hr.\n Action:\n Additional sedation given for agitation during suctioning\n Response:\n Pt more sedate. This am ABG 7.37/39/95/23/97%\n Plan:\n After IABP d/c\nd and groin stable wean sedation and vent.\n Anemia, other\n Assessment:\n Last Hct 30.3\n Action:\n This am Hct pending\n Response:\n Hct this am 33.\n Plan:\n Monitor Hct . Transfuse for a Hct <30\n Altered mental status (not Delirium)\n Assessment:\n Pt on Fentanyl and versed\n Action:\n Provide additional sedation as needed for agitation when suctioned\n Response:\n Sedation effective.\n Provide emotional support. Additional sedation as needed\n" }, { "category": "Nursing", "chartdate": "2140-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 455414, "text": "49 y/o F w/ CAD, presents from OSH w/ unrevascularized STEMI and\n cardiogenic shock, intubated w/ difficulty weaning from IABP. \n Echo EF 40-50%, 2+ TR w/ extensive left ventricle contractile\n dysfunction compared to echo .\n Shock, cardiogenic\n Assessment:\n Received pt on 1:1 with heparin off in anticipation of d/c of\n IABP.hemodynamically stable.\n Action:\n IABP pulled at 9:45am. Started captopril increased to 12.5mg at 1400.\n after IABP pulled sedation weaned in anticipation of extubation. HR and\n BP increased,frothy secretions. Lasix given and NTG drip started.\n Heparin drip restarted at 1630 @ 1600 units/hr\n Response:\n Safely extubated . Great response to lasix.\n Plan:\n Follow hemodynamics and increase captopril as tolerated. Carvedilol to\n be added. Check PTT at 2230.\n Pneumonia, other\n Assessment:\n Intubated on CMV 50% 500 x14.\n Action:\n After IABP d/ced weaned vent to PSV 10 then 5.sedation also weaned.\n first attempt at SBT increase in frothy secretions given lasix.\n Extubated about 1600.\n Response:\n Plan:\n" }, { "category": "ECG", "chartdate": "2140-05-02 00:00:00.000", "description": "Report", "row_id": 202423, "text": "Sinus rhythm\nST segment elevation in leads V1-V4 with poor R wave progression - suggest\nanterior myocardial infarction - possibly acute\nLateral ST-T changes are nonspecific\nSince previous tracing of , faster rate present\n\n" }, { "category": "ECG", "chartdate": "2140-04-30 00:00:00.000", "description": "Report", "row_id": 202424, "text": "Sinus rhythm. Poor R wave progression. Consider prior anteroseptal myocardial\ninfarction versus a normal variant. Compared to tracing #1 the inferior and\nlateral ST-T wave changes are not seen on the current tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2140-04-29 00:00:00.000", "description": "Report", "row_id": 202425, "text": "Sinus rhythm. Right atrial abnormality. Poor R wave progression. Consider\nprior anteroseptal myocardial infarction versus a normal variant. Inferior\nand lateral ST-T wave changes are non-specific but may be due to myocardial\nischemia. Clinical correlation is suggested. Compared to the previous tracing\nof poor R wave progression and lateral and inferior changes are seen\non the current tracing. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2140-05-02 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1075333, "text": " 2:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: 49 yr old female s/p extubation, now in resp distress\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n sob\n REASON FOR THIS EXAMINATION:\n 49 yr old female s/p extubation, now in resp distress\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n Portable AP chest radiograph was compared to obtained at 08:16\n a.m.\n\n The patient was extubated in the meantime interval with removal of the NG\n tube. The pacemaker defibrillator lead terminates in the right ventricle.\n The post-sternotomy wires are intact. The cardiomediastinal silhouette is\n stable. There is interval improvement of aeration of the right lung base with\n still present bibasilar opacities, which might represent areas of atelectasis.\n No overt pleural effusion is demonstrated, although small amount of pleural\n fluid cannot be entirely excluded. The right subclavian line tip is in mid\n SVC.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2122-12-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 601429, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology and EP was consulted for possible tachy-brady syndrome and\n the possible need for a pacemaker or temp wire. Tx CCU\n Atrial fibrillation (Afib)\n Assessment:\n AF 98-120s. BP stable. Echo: LVEF 45% 1-2+MR. Remains in AF with\n RVR\n Action:\n Pacer pads removed. Pacer/defibrillator remains in room.\n LS rhonchi, occ crackles to bases.\n Congested productive cough. O2 2L -> sats >98%.\n Response:\n Remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan for PPM am, NPO\n after midnight. As per team, if patient needs something to slow her AF\n between now and , use a one time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o . Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching. L great toe reddened and\n foot sensitive to touch. CCU team aware.\n Coccyx slightly pink, blanches, looks like old scarring on\n coccyx.\n Reposittioned q2hrs.\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Pneumoboots off per patient request\n pt now taking s/c\n heparin tid (pt had been refusing).\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n" }, { "category": "Physician ", "chartdate": "2122-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601403, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -Plan for PPM placement , EP. No temp wire in, pacer pads on\n and Atropine in room.\n -Next HD session , Renal.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 104 (94 - 121) bpm\n BP: 106/53(65) {96/48(58) - 156/91(102)} mmHg\n RR: 16 (16 - 32) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 620 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 620 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GEN: NAD, resting comfortably in bed, conversational.\n CV: Irregularly irregular, GI/VI holosystolic murmer at apex\n PULM: CTAB anteriorly; pt refusing to sit up for exam\n ABD; Soft, NT/ND +BS\n EXTR: No pedal edema, warm, well perfused\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pAfib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses, awaiting PPM placement .\n .\n # RHYTHM: Symptoms and rhythm consistent with tachy-brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. Patient is very sensitive to\n beta blockers, becomes bradycardic. Currently hemodynamically stable\n with no pauses overnight. HR in 100s to 120s primarily overnight.\n - Permanent pacemaker placement planned for \n - Atropine in room, pacer pads on patient\n - Monitor on telemetry\n - Avoid beta blockers given h/o bradycardia/pauses\n - No anticoagulation given hx of GIB\n .\n # PUMP: EF 45% on recent TTE. Currently without evidence of volume\n overload.\n -Fluid removal via HD per renal protocol\n .\n # CAD: No evidence of acute ischemia.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda.\n -Continue ASA/Plavix\n -F/U vascular recs\n .\n # ESRD:\n - Continue HD per regimen; next HD session , Renal\n .\n # Hypothyroidism: Stable, continue home levothyroxine\n ICU Care\n Nutrition: Cardiac diet. NPO midnight tonight for PPM placement\n tomorrow.\n Glycemic Control:\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT: SC Heparin (patient reportedly refusing shots)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: (HCP) , ,\n Cell \n Code status: Full code\n Disposition: CCU for now for close HR monitoring.\n ------ Protected Section ------\n EP Fellow Addendum:\n Pt seen and examined, discussed with housestaff.\n -No overnight events, no pauses\n -Continued AF at 110\n -Feels well without complaints\n PE:\n HR 100-110 BP 106/60\n NAD\n CTA B/L\n Irreg, tachy, HSM at apex\n Soft, NTND\n WWP, no edema\n Labs and tele reviewed\n A/P: 81 yo F with ESRD on HD via RUE fistula with tachy-brady c/b\n frequent long pauses, now stable with AF in 110\ns off nodal agents for\n PPM tomorrow.\n -Continue atropine and pads at bedside\n -Avoid vagal maneuvers\n -NPO at midnight for PPM\n -Hold nodal agents as you are, tolerating increased HR; initiate\n therapy after PM placement\n Rest of plan per housestaff.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:31 ------\n" }, { "category": "Physician ", "chartdate": "2122-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601408, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -Plan for PPM placement , EP. No temp wire in, pacer pads on\n and Atropine in room.\n -Next HD session , Renal.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 104 (94 - 121) bpm\n BP: 106/53(65) {96/48(58) - 156/91(102)} mmHg\n RR: 16 (16 - 32) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 620 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 620 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GEN: NAD, resting comfortably in bed, conversational.\n CV: Irregularly irregular, GI/VI holosystolic murmer at apex\n PULM: CTAB anteriorly; pt refusing to sit up for exam\n ABD; Soft, NT/ND +BS\n EXTR: No pedal edema, warm, well perfused\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pAfib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses, awaiting PPM placement .\n .\n # RHYTHM: Symptoms and rhythm consistent with tachy-brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. Patient is very sensitive to\n beta blockers, becomes bradycardic. Currently hemodynamically stable\n with no pauses overnight. HR in 100s to 120s primarily overnight.\n - Permanent pacemaker placement planned for \n - Atropine in room, pacer pads on patient\n - Monitor on telemetry\n - Avoid beta blockers given h/o bradycardia/pauses\n - No anticoagulation given hx of GIB\n .\n # PUMP: EF 45% on recent TTE. Currently without evidence of volume\n overload.\n -Fluid removal via HD per renal protocol\n .\n # CAD: No evidence of acute ischemia.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda.\n -Continue ASA/Plavix\n -F/U vascular recs\n .\n # ESRD:\n - Continue HD per regimen; next HD session , Renal\n .\n # Hypothyroidism: Stable, continue home levothyroxine\n ICU Care\n Nutrition: Cardiac diet. NPO midnight tonight for PPM placement\n tomorrow.\n Glycemic Control:\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT: SC Heparin (patient reportedly refusing shots)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: (HCP) , ,\n Cell \n Code status: Full code\n Disposition: CCU for now for close HR monitoring.\n ------ Protected Section ------\n EP Fellow Addendum:\n Pt seen and examined, discussed with housestaff.\n -No overnight events, no pauses\n -Continued AF at 110\n -Feels well without complaints\n PE:\n HR 100-110 BP 106/60\n NAD\n CTA B/L\n Irreg, tachy, HSM at apex\n Soft, NTND\n WWP, no edema\n Labs and tele reviewed\n A/P: 81 yo F with ESRD on HD via RUE fistula with tachy-brady c/b\n frequent long pauses, now stable with AF in 110\ns off nodal agents for\n PPM tomorrow.\n -Continue atropine and pads at bedside\n -Avoid vagal maneuvers\n -NPO at midnight for PPM\n -Hold nodal agents as you are, tolerating increased HR; initiate\n therapy after PM placement\n Rest of plan per housestaff.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:31 ------\n Pt seen, discussed examined with Dr agree with assessment and\n plan for PM tomorrow so she can take BB and Amiodarone. To go to 3\n today. Dialysis tomorrow. I would get anesthesia for her PM.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:16 ------\n" }, { "category": "Physician ", "chartdate": "2122-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601389, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -PPM , EP. No temp wire in, pads on and Atropine in room.\n -per Renal, HD yesterday, next session Mon.\n -No nodal agents on this pt; Tachy/brady syndrome.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 104 (94 - 121) bpm\n BP: 106/53(65) {96/48(58) - 156/91(102)} mmHg\n RR: 16 (16 - 32) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 620 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 620 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GEN: NAD, resting comfortably in bed, conversational.\n NEURO: slight droop to right lip\n CV: Irregularly irregular, no m/r/g\n PULM: CTAB anteriorly\n ABD; soft, nt, nd\n EXTR: skinny\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pA.fib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses. No events overnight.\n .\n # RHYTHM: Symptoms and rhythm consistent with tachy-brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. However, it is clear she is\n very sensitive to beta blockers. Currently hemodynamically stable with\n no pauses since 1pm yesterday. HR in 100s to 120s primarily overnight.\n - Hold on temp wire for now\n - Atropine in room, pacer pads on patient\n - Monitor on telemetry\n - Will need permanent pacemaker, will discuss with family. Likely to\n be done on , electively.\n - Avoid beta blockers given h/o bradycardia/pauses\n - f/u ECG\n - No anticoagulation given hx of GIB\n .\n # PUMP: difficult to assess volume status today on exam\n seems more\n along the lines of euvolemia.\n -Fluid removal via HD per renal protocol\n .\n # CAD: No signs of ischemia currently.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda\n - Continue aspirin/plavix\n - F/U vascular recs\n .\n # ESRD:\n - Continue HD per regimen, for volume/electrolyte control\n .\n # Hypothyroidism:\n - Cont. levothyroxine\n .\n FEN: Cardiac diet (no longer NPO as not planning on pacemaker placement\n today)\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with HSC (note, patient refusing)\n -Bowel regimen\n .\n CODE: full\n .\n COMM: (HCP) , , Cell \n .\n DISPO: CCU for now for close HR monitoring.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2122-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601400, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -Plan for PPM placement , EP. No temp wire in, pacer pads on\n and Atropine in room.\n -Next HD session , Renal.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 104 (94 - 121) bpm\n BP: 106/53(65) {96/48(58) - 156/91(102)} mmHg\n RR: 16 (16 - 32) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 620 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 620 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GEN: NAD, resting comfortably in bed, conversational.\n CV: Irregularly irregular, GI/VI holosystolic murmer at apex\n PULM: CTAB anteriorly; pt refusing to sit up for exam\n ABD; Soft, NT/ND +BS\n EXTR: No pedal edema, warm, well perfused\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pAfib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses, awaiting PPM placement .\n .\n # RHYTHM: Symptoms and rhythm consistent with tachy-brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. Patient is very sensitive to\n beta blockers, becomes bradycardic. Currently hemodynamically stable\n with no pauses overnight. HR in 100s to 120s primarily overnight.\n - Permanent pacemaker placement planned for \n - Atropine in room, pacer pads on patient\n - Monitor on telemetry\n - Avoid beta blockers given h/o bradycardia/pauses\n - No anticoagulation given hx of GIB\n .\n # PUMP: EF 45% on recent TTE. Currently without evidence of volume\n overload.\n -Fluid removal via HD per renal protocol\n .\n # CAD: No evidence of acute ischemia.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda.\n -Continue ASA/Plavix\n -F/U vascular recs\n .\n # ESRD:\n - Continue HD per regimen; next HD session , Renal\n .\n # Hypothyroidism: Stable, continue home levothyroxine\n ICU Care\n Nutrition: Cardiac diet. NPO midnight tonight for PPM placement\n tomorrow.\n Glycemic Control:\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT: SC Heparin (patient reportedly refusing shots)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: (HCP) , ,\n Cell \n Code status: Full code\n Disposition: CCU for now for close HR monitoring.\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601243, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 12:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.1\nC (97\n HR: 116 (104 - 122) bpm\n BP: 133/72(88) {84/53(63) - 138/79(92)} mmHg\n RR: 17 (15 - 30) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 140 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 140 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601244, "text": "TITLE:\n Chief Complaint:\n Hungry.\n 24 Hour Events:\n NASAL SWAB - At 12:26 AM\n No events with rate/rhythm overnight (ie: no extended pauses).\n Continues in atrial fibrillation, HR in 100s.\n No CP, SOB, AP. Hungry.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.1\nC (97\n HR: 116 (104 - 122) bpm\n BP: 133/72(88) {84/53(63) - 138/79(92)} mmHg\n RR: 17 (15 - 30) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 140 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 140 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///34/\n Physical Examination\n GEN: NAD, resting comfortably in bed, conversational.\n NEURO: slight droop to right lip\n CV: Irregularly irregular, no m/r/g\n PULM: CTAB anteriorly\n ABD; soft, nt, nd\n EXTR: skinny\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pA.fib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses. No events overnight.\n .\n # RHYTHM: Symptoms and rhythm consistent with tachy-brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. However, it is clear she is\n very sensitive to beta blockers. Currently hemodynamically stable with\n no pauses since 1pm yesterday. HR in 100s to 120s primarily overnight.\n - Hold on temp wire for now\n - Atropine in room, pacer pads on patient\n - Monitor on telemetry\n - Will need permanent pacemaker, will discuss with family. Likely to\n be done on Monday, electively.\n - Avoid beta blockers given h/o bradycardia/pauses\n - f/u ECG\n - No anticoagulation given hx of GIB\n .\n # PUMP: difficult to assess volume status today on exam\n seems more\n along the lines of euvolemia.\n -Fluid removal via HD per renal protocol\n .\n # CAD: No signs of ischemia currently.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda\n - Continue aspirin/plavix\n - F/U vascular recs\n .\n # ESRD:\n - Continue HD per regimen, for volume/electrolyte control\n .\n # Hypothyroidism:\n - Cont. levothyroxine\n .\n FEN: Cardiac diet (no longer NPO as not planning on pacemaker placement\n today)\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with HSC (note, patient refusing)\n -Bowel regimen\n .\n CODE: full\n .\n COMM: (HCP) , , Cell \n .\n DISPO: CCU for now for close HR monitoring.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2122-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 601248, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology (EP) was consulted for possible tachy-brady syndrome and the\n possible need for a pacemaker. Tx to CCU for monitoring and possible\n temp wire placement and permanent pacemaker insertion.\n Atrial fibrillation (Afib)\n Assessment:\n Echo: LVEF 45% 1-2+MR. Remains in AF with RVR\n Action:\n Pacer pads attached to patient and to bedside\n defibrillator/pacer. Pacer off.\n Diet advanced, as no procedure today\n Lungs monitored, crackles\n ^ bilaterally, on 2L np with\n sats mid 90\ns except when sleeping, drifting to 89% with sleep,\n therefore, O2 ^ to 4L Np with sleep.\n Response:\n remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan to discuss permanent\n pacemaker with pt and her neice, with potential plan for pacing \n morning. Will need to be NPO after midnight. As per team, if patient\n needs something to slow her AF between now and , use a one\n time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o overnite. Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching\n Coccyx slightly pink, blanches\n Turned off of back and reason for this explained to patient\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Response:\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 601227, "text": "TITLE: EP Fellow Progress Note\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -NO pauses overnight while in CCU\n -AF in 100's, tolerting well\n -No complaints this am\n Medications\n Unchanged\n Plavix 75 mg daily\n ASA 81 mg daily\n Levoxyl 88 mcg daily\n Physical Exam\n General appearance: NAD, sleeping\n BP: 102 / 64 mmHg\n HR: 109 bpm\n RR: 18 insp/min\n Tmax C last 24 hours: 37.2 C\n Tmax F last 24 hours: 98.9 F\n T current C: 36.1 C\n T current F: F\n O2 sat: 98 % on Supplemental oxygen: 2 L\n Previous day:\n Weight: 50 kg\n Output: 0 mL\n Fluid balance: 0 mL\n Today:\n Intake: 66 mL\n Output: 0 mL\n Fluid balance: 66 mL\n HEENT: (Oral mucosa: Moist)\n Cardiovascular: (Auscultation: Irreg, 2/6HSM at apex), (Palpation:\n +Heave)\n Respiratory: (Auscultation: Coarse basal BS)\n Abdomen: (Palpation: soft, NTND)\n Neurological: (Orientation: alert, aware)\n Extremities:\n Right: (Edema: None)\n Left: (Edema: None)\n Other: Right foot in boot\n Labs\n 152\n 10.5\n 74\n 3.9\n 34\n 4.3\n 18\n 97\n 139\n 31.8\n 6.3\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hgb\n 10.5\n Hct (Serum)\n 31.8\n Plt\n 152\n INR\n 1.3\n PTT\n 31.9\n Na+\n 139\n K + (Serum)\n 4.3\n Cl\n 97\n HCO3\n 34\n BUN\n 18\n Creatinine\n 3.9\n Glucose\n 74\n ABG: / / / 34 / Values as of 04:15 AM\n Tests\n Telemetry: AF in 110's, no pauses\n Assessment and Plan\n 81 yaer old female with PAD s/p recent LE angioplasty with -brady\n syndrome, multiple long pauses with ? vagal component over last 2 days,\n now in AF.\n 1. Tachy-brady:\n -Plan for PPM on Monday\n -No obvious need for temp wire now as no pauses while off meds; can\n readdress as needed over weekend\n -Atropine and pads at bedside\n -Hold nodal agents, tolerate HR 110's for now\n Rest of plan per housestaff.\n ------ Protected Section ------\n Patient seen, discussed, examined with Dr. , agree with\n assessment and plans for PM Monday. No AVN blocking agents until then.\n No pauses or hypotension overnite\n .\n ------ Protected Section Addendum Entered By: , MD\n on: 09:26 ------\n" }, { "category": "Nursing", "chartdate": "2122-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 601293, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology (EP) was consulted for possible tachy-brady syndrome and the\n possible need for a pacemaker. Tx to CCU for monitoring and possible\n temp wire placement and permanent pacemaker insertion.\n Atrial fibrillation (Afib)\n Assessment:\n Echo: LVEF 45% 1-2+MR. Remains in AF with RVR\n Action:\n Pacer pads attached to patient and to bedside\n defibrillator/pacer. Pacer off.\n Diet advanced, as no procedure today\n Lungs monitored, crackles\n ^ bilaterally, on 2L np with\n sats mid 90\ns except when sleeping, drifting to 89% with sleep,\n therefore, O2 ^ to 4L Np with sleep.\n Response:\n remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan to discuss permanent\n pacemaker with pt and her niece, with potential plan for pacing \n morning. Will need to be NPO after midnight. As per team, if patient\n needs something to slow her AF between now and , use a one\n time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o overnite. Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching\n Coccyx slightly pink, blanches\n Turned off of back and reason for this explained to patient\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Response:\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n" }, { "category": "Nursing", "chartdate": "2122-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 601352, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology and EP was consulted for possible tachy-brady syndrome and\n the possible need for a pacemaker or temp wire. Tx CCU\n Atrial fibrillation (Afib)\n Assessment:\n AFIB 100s-130s. BP stable. Echo: LVEF 45% 1-2+MR. Remains in AF\n with RVR\n Action:\n Pacer pads attached to patient and to bedside\n defibrillator/pacer. Pacer off.\n LS rhonchi, occ crackles to bases.\n Congested productive cough. O2 2L overnite sats >98%.\n Response:\n remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan for PPM am, NPO\n after midnight. As per team, if patient needs something to slow her AF\n between now and , use a one time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o overnite. Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching\n Coccyx slightly pink, blanches, looks like old scarring on\n coccyx.\n Turned off of back and reason for this explained to patient\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Pneumoboots off per patient request\n pt now taking s/c\n heparin tid (pt had been refusing).\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601204, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 12:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.1\nC (97\n HR: 105 (105 - 122) bpm\n BP: 97/57(67) {97/57(67) - 138/79(92)} mmHg\n RR: 15 (15 - 30) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pA.fib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses.\n .\n # RHYTHM:Symptoms and rhythm consistent with tachy brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. However, it is clear she is\n very sensitive to beta blockers. Currently HD stable with no pauses\n since 1pm on .\n - Hold on temp wire for now\n - Atropine in room, pacer pads on\n - Monitor on telemetry\n - Will need permanent pacemaker, will discuss with family.\n - Avoid beta blockers\n - f/u AM ECG\n - No anticoagulation given hx of GIB\n .\n # PUMP: Slightly volume overloaded by exam today.\n -Fluid removal via HD\n .\n # CAD: No signs of ischemia currently.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda\n - Continue aspirin/plavix\n - F/U vascular recs\n .\n # Hypothyroidism:\n - Con't levothyroxine\n .\n FEN: Cardiac diet\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with HSC\n -Bowel regimen\n .\n CODE: full\n .\n COMM: (HCP) , , Cell \n .\n DISPO: CCU for now\n ICU Care\n Nutrition: Cardiac, heart-healthy\n Glycemic Control: monitor blood sugars for now\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT: hep SQ (note\n she has been refusing); pneumoboots\n Stress ulcer:\n VAP: not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2122-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 601178, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology (EP) was consulted for possible tachy-brady syndrome and the\n possible need for a pacemaker. Tx to CCU for monitoring and possible\n temp wire placement and permanent pacemaker insertion.\n Atrial fibrillation (Afib)\n Assessment:\n AF with inverted Twaves 90-120s (pt has had episodes of symptomatic\n sinus pauses- no pauses since 1pm ). SBP 110-130s. 2 PIVs. \n Echo: LVEF 45% 1-2+MR.\n Action:\n Pacer pads attached to patient and to bedside defibrillator/pacer.\n Pacer off. Pt NPO. On ASA and Plavix. Pt has been refusing heparin s/c\n on floor. CCU team aware. Placed on pneumoboots.\n Response:\n No temp pacer wires placed as pt without arrhythmias other than AF\n overnite.\n Plan:\n Con\nt to monitor for tachy brady syndrome. EP following . possible PPM\n placement. Keep NPO until plan determined in am rounds w/ CCU team.\n Con\nt pneumoboots.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF. Foley d/c\nd \n pt due to void\n (but dialysis patient\n only 10cc/day)\n Action:\n No u/o overnite. Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on Monday. Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission LT heel not blanching. Sheep skin\n under heels on arrival. Coccyx reddened blanching in areas.\n Action:\n Aloe vesta to heels and coccyx. Turned q2h. heels elevated with\n pillows. Waffle boots placed bilat.\n Response:\n Heels still red\n Rt blanching, Lt still not blanching. Coccyx\n improved, but looks like old scarring on buttocks. Con\nt to monitor.\n Plan:\n Watch coccyx for improvement. Monitor heels. Skin care. Turns q2h. keep\n heels off bed/waffles.\n" }, { "category": "Nursing", "chartdate": "2122-12-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 601425, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology and EP was consulted for possible tachy-brady syndrome and\n the possible need for a pacemaker or temp wire. Tx CCU\n Atrial fibrillation (Afib)\n Assessment:\n AFIB 100s-130s. BP stable. Echo: LVEF 45% 1-2+MR. Remains in AF\n with RVR\n Action:\n Pacer pads attached to patient and to bedside\n defibrillator/pacer. Pacer off.\n LS rhonchi, occ crackles to bases.\n Congested productive cough. O2 2L -> sats >98%.\n Response:\n remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan for PPM am, NPO\n after midnight. As per team, if patient needs something to slow her AF\n between now and , use a one time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o . Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching\n Coccyx slightly pink, blanches, looks like old scarring on\n coccyx.\n Turned off of back and reason for this explained to patient\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Pneumoboots off per patient request\n pt now taking s/c\n heparin tid (pt had been refusing).\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n" }, { "category": "Nursing", "chartdate": "2122-12-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 601426, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology and EP was consulted for possible tachy-brady syndrome and\n the possible need for a pacemaker or temp wire. Tx CCU\n Atrial fibrillation (Afib)\n Assessment:\n AF 98-120s. BP stable. Echo: LVEF 45% 1-2+MR. Remains in AF with\n RVR\n Action:\n Pacer pads removed. Pacer/defibrillator remains in room.\n LS rhonchi, occ crackles to bases.\n Congested productive cough. O2 2L -> sats >98%.\n Response:\n remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan for PPM am, NPO\n after midnight. As per team, if patient needs something to slow her AF\n between now and , use a one time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o . Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching\n Coccyx slightly pink, blanches, looks like old scarring on\n coccyx.\n Turned off of back and reason for this explained to patient\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Pneumoboots off per patient request\n pt now taking s/c\n heparin tid (pt had been refusing).\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n" }, { "category": "Nursing", "chartdate": "2122-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 601168, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology (EP) was consulted for possible tachy-brady syndrome and the\n possible need for a pacemaker. Tx to CCU for monitoring and possible\n temp wire placement and permanent pacemaker insertion.\n Atrial fibrillation (Afib)\n Assessment:\n AF with inverted Twaves 90-120s (pt has had episodes of symptomatic\n sinus pauses- no pauses since 1pm ). SBP 110-130s. 2 PIVs. \n Echo: LVEF 45% 1-2+MR.\n Action:\n Pacer pads attached to patient and to bedside defibrillator/pacer.\n Pacer off. Pt NPO. On ASA and Plavix. Pt has been refusing heparin s/c\n on floor. CCU team aware. Placed on pneumoboots.\n Response:\n No temp pacer wires placed as pt without arrhythmias other than AF\n overnite.\n Plan:\n Con\nt to monitor for tachy brady syndrome. EP following . possible PPM\n placement. Keep NPO until plan determined in am rounds w/ CCU team.\n Con\nt pneumoboots.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF. Foley d/c\nd \n pt due to void\n (but dialysis patient\n only 10cc/day)\n Action:\n No u/o overnite. Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on Monday. Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission LT heel not blanching. Sheep skin\n under heels on arrival. Coccyx reddened blanching in areas.\n Action:\n Aloe vesta to heels and coccyx. Turned q2h. heels elevated with\n pillows. Waffle boots placed bilat.\n Response:\n Heels still red\n Rt blanching, Lt still not blanching. Coccyx\n improved, but looks like old scarring on buttocks. Con\nt to monitor.\n Plan:\n Watch coccyx for improvement. Heels red.\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 601138, "text": "TITLE:\n Date of service: \n Initial visit, Cardiology service: CCU\n Presenting complaint: Arrhythmia\n History of present illness: 81F with a history of ESRD on dialysis and\n paroxysmal atrial fibrillation not on anticoagulation due to history of\n GI bleed and fall risk admitted for angioplasty of her left iliac\n artery who developed atrial fibrillation to 140s during angioplasty on\n for symptomatic leg ischemia. She received multiple IV boluses of\n lopressor as well as 25mg PO x 2 with eventual decrease in heart rates\n to 100s. She was noted to have several bradycardic episodes to 30s (\n second pauses) with blood pressures remaining in 100s. While speaking\n to the resident this morning, she again developed heart rates in the\n 30s and reported feeling dizzy and became diaphoretic. She also had a\n single 10 second pause at dialysis today also associated with some\n lightheadedness. She was also noted to have pauses on telemetry. Per\n the patient's PCP, has been treated in the past with small doses of\n betablocker which resulted in bradycardia. Thus, this was discontinued\n and by report, she has not been troubled by rapid heart rates.\n Cardiology (EP) was consulted for possible tachy-brady syndrome and the\n possible need for a pacemaker\n On cardiac review of symptoms, she denies chest pain. She does\n report occasional dizziness at home and at hemodialysis,\n exertional SOB and .\n Past medical history: 1. CARDIAC RISK FACTORS: +Diabetes,\n +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG:\n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD:\n 3. OTHER PAST MEDICAL HISTORY:\n 1. Congestive heart failure\n 2. Hypothyroidism\n 3. Atrial fibrillation\n 4. End-stage renal disease on dialysis\n 5. Peripheral vascular disease\n Cardiac Risk Factors include diabetes, dyslipidemia,\n hypertension, tobacco use and family history of CAD\n CAD Risk Factors\n CAD Risk Factors Present\n Diabetes mellitus, Dyslipidemia, Hypertension, Family Hx of CAD\n CAD Risk Factors Absent\n Family Hx of sudden cardiac death\n (Tobacco: Yes), (Quit: Yes)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies: NKDA\n No Known Drug Allergies\n Current medications: MEDICATIONS at HOME:\n Levothyroxine 88 mcg QD,\n Oxazepam 15 mg Capsule QHS\n asa 81mg PO daily\n .\n Medications on Transfer:\n levoxyl 88mcg qd\n plavix 75mg qd\n ASA 81mg qd\n heparin 5000u sc tid\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Presyncope, Lightheadedness\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea, Edema,\n Palpitations, Syncope\n Review of Systems\n Organ system ROS normal\n Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,\n Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,\n Neurological, Psychiatric, Allergy / Immune\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,\n Bleeding during surgery, Joint pains, Myalgias\n Social History\n (Alcohol: Yes), (Recreational drug use: No)\n Family history: The patient's father died secondary to coronary artery\n disease at the age 66. The patient's sister died at age 51 secondary\n to myocardial infarction. The patient's mother has diabetes mellitus.\n Social history details: former smoker, history of EtOH abuse, no\n recreational drugs\n Physical Exam\n Height: 63 Inch, 160 cm\n BP right arm:\n 127 / 64 mmHg\n Weight: 50 kg\n T current: 98.9 C\n HR: 111 bpm\n O2 sat: 98 % on Supplemental oxygen: 2L NC\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: JVP, slightly elevated), (Thyroid: WNL)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: Abnormal, bibasilar\n crackles)\n Cardiac: (Rhythm: Irregular, tachy), (Palpation / PMI: WNL),\n (Auscultation: S1: WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis\n artery: Right: 1, Left: 1), (Posterior tibial artery: Right: 1, Left:\n 1), (Edema: Right: 1+, Left: 1+)\n Tests\n ECG: EKG: atrial fibrillation at 128 bpm, inverted t waves\n V4-V6. Prior EKGs not available for review; prior EKGs reported\n as atrial fibrillation and LVH with ST-T changes.\n .\n TELEMETRY: Multiple second pauses but none since 1pm \n .\n 2D-ECHOCARDIOGRAM :\n The left atrium is elongated. There is mild symmetric left ventricular\n hypertrophy with normal cavity size. There is mild global left\n ventricular hypokinesis (LVEF = 45 %). There is considerable\n beat-tobeat variability of the left ventricular ejection fraction due\n to an irregular rhythm/premature beats. Right ventricular chamber size\n and free wall motion are normal. The ascending aorta is moderately\n dilated. The aortic valve leaflets (3) are mildly thickened but aortic\n stenosis is not present. Trace aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. There is no mitral valve prolapse.\n Mild to moderate (+) mitral regurgitation is seen. The left\n ventricular inflow pattern suggests a restrictive filling abnormality,\n with elevated left atrial pressure.\n Compared with the report of the prior study (images unavailable for\n review) of , left ventricular systolic function is mildly\n depressed and mild to moderate mitral regurgitation is now present\n .\n ETT : negative persantine MIBI\n .\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pA.fib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses.\n .\n # RHYTHM:Symptoms and rhythm consistent with tachy brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. However, it is clear she is\n very sensitive to beta blockers. Currently HD stable with no pauses\n since 1pm.\n - Hold on temp wire for now\n - Atropine in room, pacer pads on\n - Monitor on telemetry\n - Will need permanent pace , discuss with family.\n - Avoid beta blockers\n - ECG in am\n - No anticoagulation given hx of GIB\n .\n # PUMP: Slightly volume overloaded by exam today.\n -Fluid removal via HD\n .\n # CAD: No signs of ischemia currently.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda\n - Continue aspirin/plavix\n - F/U vascular recs\n .\n # Hypothyroidism:\n - Con't levothyroxine\n .\n FEN: Cardiac diet\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with HSC\n -Bowel regimen\n .\n CODE: full\n .\n COMM: (HCP) , , Cell \n .\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2122-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 601140, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTNadmitted for angioplasty for occlusion of left iliac\n artery for symptomatic leg ischemia who developed atrial fibrillation\n to 140s during angioplasty on . She received multiple IV boluses\n of lopressor as well as 25mg PO x 2 with eventual decrease in heart\n rates to 100s. She was noted to have several bradycardic episodes\n (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology (EP) was consulted for possible tachy-brady syndrome and the\n possible need for a pacemaker. Tx to CCU for monitoring and possible\n temp wire placement and permanent pacemaker insertion.\n Atrial fibrillation (Afib)\n Assessment:\n AF with inverted Twaves 90-120s (pt has had episodes of symptomatic\n sinus pauses- no pauses since 1pm ). SBP 110-130s. 2 PIVs. \n Echo: LVEF 45% 1-2+MR.\n Action:\n Pacer pads attached to patient and to bedside defibrillator/pacer.\n Pacer off. Pt NPO. On ASA and Plavix. Pt has been refusing heparin s/c\n on floor. CCU team aware. Placed on pneumoboots.\n Response:\n No temp pacer wires placed as pt without arrhythmias other than AF\n overnite.\n Plan:\n Con\nt to monitor for tachy brady syndrome. EP following . possible PPM\n placement. Keep NPO until plan determined in am rounds w/ CCU team.\n Con\nt pneumoboots.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF. Foley d/c\nd \n pt due to void\n (but dialysis patient\n only 10cc/day)\n Action:\n No u/o overnite. Last HD on .\n Response:\n Con\nt to monitor labs and u/o.\n Plan:\n Due for HD on Monday. Follow labs. Renal team following.\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 601208, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 12:26 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.1\nC (97\n HR: 105 (105 - 122) bpm\n BP: 97/57(67) {97/57(67) - 138/79(92)} mmHg\n RR: 15 (15 - 30) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 152 K/uL\n 10.5 g/dL\n 74 mg/dL\n 3.9 mg/dL\n 34 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 97 mEq/L\n 139 mEq/L\n 31.8 %\n 6.3 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hct\n 31.8\n Plt\n 152\n Cr\n 3.9\n Glucose\n 74\n Other labs: PT / PTT / INR:14.6/31.9/1.3, Differential-Neuts:71.9 %,\n Lymph:18.3 %, Mono:5.9 %, Eos:3.7 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Assessment and Plan\n This is an 81 year old female with a history of CHF, pA.fib, and ESRD\n disease who presents with episodes of a.fib with RVR interspersed with\n symptomatic sinus pauses.\n .\n # RHYTHM:Symptoms and rhythm consistent with tachy brady syndrome but\n with rapid onset of symptoms even with a second pause suggests a\n possible vagal component to these pauses. However, it is clear she is\n very sensitive to beta blockers. Currently HD stable with no pauses\n since 1pm on .\n - Hold on temp wire for now\n - Atropine in room, pacer pads on\n - Monitor on telemetry\n - Will need permanent pacemaker, will discuss with family.\n - Avoid beta blockers\n - f/u AM ECG\n - No anticoagulation given hx of GIB\n .\n # PUMP: Slightly volume overloaded by exam today.\n -Fluid removal via HD\n .\n # CAD: No signs of ischemia currently.\n -Continue ASA/Plavix\n .\n # PAD: S/p angioplasty of left iliac and profunda\n - Continue aspirin/plavix\n - F/U vascular recs\n .\n # Hypothyroidism:\n - Con't levothyroxine\n .\n FEN: Cardiac diet\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with HSC\n -Bowel regimen\n .\n CODE: full\n .\n COMM: (HCP) , , Cell \n .\n DISPO: CCU for now\n ICU Care\n Nutrition: Cardiac, heart-healthy\n Glycemic Control: monitor blood sugars for now\n Lines:\n 20 Gauge - 10:52 PM\n Prophylaxis:\n DVT: hep SQ (note\n she has been refusing); pneumoboots\n Stress ulcer:\n VAP: not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2122-12-05 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 601223, "text": "TITLE: EP Fellow Progress Note\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -NO pauses overnight while in CCU\n -AF in 100's, tolerting well\n -No complaints this am\n Medications\n Unchanged\n Plavix 75 mg daily\n ASA 81 mg daily\n Levoxyl 88 mcg daily\n Physical Exam\n General appearance: NAD, sleeping\n BP: 102 / 64 mmHg\n HR: 109 bpm\n RR: 18 insp/min\n Tmax C last 24 hours: 37.2 C\n Tmax F last 24 hours: 98.9 F\n T current C: 36.1 C\n T current F: F\n O2 sat: 98 % on Supplemental oxygen: 2 L\n Previous day:\n Weight: 50 kg\n Output: 0 mL\n Fluid balance: 0 mL\n Today:\n Intake: 66 mL\n Output: 0 mL\n Fluid balance: 66 mL\n HEENT: (Oral mucosa: Moist)\n Cardiovascular: (Auscultation: Irreg, 2/6HSM at apex), (Palpation:\n +Heave)\n Respiratory: (Auscultation: Coarse basal BS)\n Abdomen: (Palpation: soft, NTND)\n Neurological: (Orientation: alert, aware)\n Extremities:\n Right: (Edema: None)\n Left: (Edema: None)\n Other: Right foot in boot\n Labs\n 152\n 10.5\n 74\n 3.9\n 34\n 4.3\n 18\n 97\n 139\n 31.8\n 6.3\n [image002.jpg]\n 04:15 AM\n WBC\n 6.3\n Hgb\n 10.5\n Hct (Serum)\n 31.8\n Plt\n 152\n INR\n 1.3\n PTT\n 31.9\n Na+\n 139\n K + (Serum)\n 4.3\n Cl\n 97\n HCO3\n 34\n BUN\n 18\n Creatinine\n 3.9\n Glucose\n 74\n ABG: / / / 34 / Values as of 04:15 AM\n Tests\n Telemetry: AF in 110's, no pauses\n Assessment and Plan\n 81 yaer old female with PAD s/p recent LE angioplasty with -brady\n syndrome, multiple long pauses with ? vagal component over last 2 days,\n now in AF.\n 1. Tachy-brady:\n -Plan for PPM on Monday\n -No obvious need for temp wire now as no pauses while off meds; can\n readdress as needed over weekend\n -Atropine and pads at bedside\n -Hold nodal agents, tolerate HR 110's for now\n Rest of plan per housestaff.\n" }, { "category": "Nursing", "chartdate": "2122-12-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 601457, "text": "81F with a history of ESRD on dialysis and paroxysmal atrial\n fibrillation not on anticoagulation due to history of GI bleed and fall\n risk, CHF, PVD, HTN, -admitted for angioplasty for occlusion of left\n iliac artery for symptomatic leg ischemia who developed atrial\n fibrillation to 140s during angioplasty on . She received multiple\n IV boluses of lopressor as well as 25mg PO x 2 with eventual decrease\n in heart rates to 100s. She was noted to have several bradycardic\n episodes (mostly during dialysis) to 30s ( second pauses) with blood\n pressures remaining in 100s. While speaking to the resident this\n morning, she again developed heart rates in the 30s and reported\n feeling dizzy and became diaphoretic. She also had a single 10 second\n pause at dialysis today also associated with some lightheadedness. She\n was also noted to have pauses on telemetry. Betablockers d/c\n Cardiology and EP was consulted for possible tachy-brady syndrome and\n the possible need for a pacemaker or temp wire. Tx CCU\n Atrial fibrillation (Afib)\n Assessment:\n AF 98-120s. BP stable. Echo: LVEF 45% 1-2+MR. Remains in AF with\n RVR\n Action:\n Pacer pads removed. Pacer/defibrillator remains in room.\n LS rhonchi, occ crackles to bases.\n Congested productive cough. O2 2L -> sats >98%.\n Response:\n Remains in AF with occ RVR up to 140\ns but only for seconds, usually\n 100-120. BP stable\n Plan:\n Con\nt to monitor for tachy brady syndrome. Plan for PPM am, NPO\n after midnight. As per team, if patient needs something to slow her AF\n between now and , use a one time dose of Pindolol.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n ESRD w/ LUE AV Fistula w/ HD MWF.\n Action:\n No u/o . Last HD on .\n Response:\n Con\nt to monitor labs and u/o. am BUN/CR 18/3.9\n Plan:\n Due for HD on . Follow labs. Renal team following.\n Impaired Skin Integrity\n Assessment:\n Both heels reddened on admission, waffle boots in place and sheep skin\n on mattress for friction\n Action:\n Heels pink but both blanching. L great toe reddened and\n foot sensitive to touch. CCU team aware.\n Coccyx slightly pink, blanches, looks like old scarring on\n coccyx.\n Reposittioned q2hrs.\n Waffle boots on alt/w heels suspended off of mattress with\n pillow.\n Pneumoboots off per patient request\n pt now taking s/c\n heparin tid (pt had been refusing).\n Plan:\n Monitor skin, heels and coccyx especially. Skin care. Turns q2h. Heels\n off of bed/ use waffles boots.\n Demographics\n Attending MD:\n FRANK B.\n Admit diagnosis:\n ARTHEROSCLEROSIS WITH ISCHEMIC REST PAIN\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 50 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: GI Bleed, HEMO or PD, Renal Failure, Smoker\n CV-PMH: Arrhythmias, CHF, Hypertension, PVD\n Additional history: ESRD on HD MWF, Rt AV fistula, GIB - pt refuses\n anticoagulation since last GIB and h/o falls, CHF, chronic AF,\n hypothyroid, foot drop - wheelchair bound, occasionally used O2 at\n home, renal artery stenosis w/ stent placement, bilat cataracts, h/o\n smoker in past.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:51\n Temperature:\n 96.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 120 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 06:16 AM\n Potassium:\n 4.1 mEq/L\n 06:16 AM\n Chloride:\n 98 mEq/L\n 06:16 AM\n CO2:\n 30 mEq/L\n 06:16 AM\n BUN:\n 29 mg/dL\n 06:16 AM\n Creatinine:\n 5.4 mg/dL\n 06:16 AM\n Glucose:\n 74 mg/dL\n 06:16 AM\n Hematocrit:\n 29.3 %\n 06:16 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 309\n Date & time of Transfer: 1600\n" }, { "category": "Echo", "chartdate": "2122-12-03 00:00:00.000", "description": "Report", "row_id": 67390, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 105\nBSA (m2): 1.49 m2\nBP (mm Hg): 104/67\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 15:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild global LV\nhypokinesis. Beat-to-beat variability on LVEF due to irregular\nrhythm/premature beats. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending\naorta. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Mild to moderate (+) MR. LV inflow pattern c/w\nrestrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Mild PR.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm appears to be\natrial fibrillation.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild global left ventricular\nhypokinesis (LVEF = 45 %). There is considerable beat-tobeat variability of\nthe left ventricular ejection fraction due to an irregular rhythm/premature\nbeats. Right ventricular chamber size and free wall motion are normal. The\nascending aorta is moderately dilated. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\nseen. The left ventricular inflow pattern suggests a restrictive filling\nabnormality, with elevated left atrial pressure.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular systolic function is mildly depressed and mild to\nmoderate mitral regurgitation is now present.\n\n\n" }, { "category": "ECG", "chartdate": "2122-12-09 00:00:00.000", "description": "Report", "row_id": 144621, "text": "Atrial fibrillation with intermittent ventricular paced beats. Anterior T wave\ninversions consistent with myocardial ischemia. Prolonged Q-T interval.\nCompared to the previous tracing of the ventricular response is slower\nand intermittent ventricular pacing is now present.\n\n" }, { "category": "ECG", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 144622, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of the ischemic appearing anterolateral ST-T wave changes\npersist. The ventricular response has slowed. Otherwise, no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 144623, "text": "Atrial fibrillation with rapid ventricular response. Compared to tracing #1\nno diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 144624, "text": "Atrial fibrillation with rapid ventricular response. Prominent T wave\ninversions in the anterolateral leads suggestive of possible ischemia.\nClinical correlation is suggested. Compared to the previous tracing\nof the ventricular rate is increased. Otherwise, no diagnostic change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2122-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103866, "text": " 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pulmonary edema?\n Admitting Diagnosis: ARTHEROSCLEROSIS WITH ISCHEMIC REST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with bilateral crackles.\n REASON FOR THIS EXAMINATION:\n Pulmonary edema?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Questionable pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a subclavian right-sided\n stent has been inserted. The size of the cardiac silhouette is unchanged.\n The lung volumes are also unchanged. On today's examination, a blunting of\n the left costodiaphragmatic sinus, potentially caused by a small pleural\n effusion, is seen. Newly appeared as a retrocardiac opacity with\n peribronchial distribution, suggestive of either atelectasis or aspiration.\n No other focal parenchymal opacities. Radiographic signs of pulmonary edema\n are not present.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-12-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1105006, "text": " 7:57 PM\n CHEST (PA & LAT) Clip # \n Reason: Lead position\n Admitting Diagnosis: ARTHEROSCLEROSIS WITH ISCHEMIC REST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pacemaker implant\n REASON FOR THIS EXAMINATION:\n Lead position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pacemaker implantation, evaluation of position.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the heart and the lung\n parenchyma show unchanged appearance. Newly inserted pacemaker in left\n pectoral position. There is no evidence of pneumothorax. The course and\n position of the leads are unremarkable. No evidence of complications.\n Unchanged small retrocardiac atelectasis. Unchanged position of the right\n subclavian stent.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717369, "text": "Neonatology Attending\nTerm infant transferred to NICU fro regular nurfsery following dusky episode\n\nMaternal hx - 39 year old G1P0->1 woman with the following prenatal screens: A positive, DAT negative, HBsAg negative, RPR non-reactive, rubella immune, GBS negaitve. PMHx notable for lyme disease (s/p treatment x 3 weeks), anemia, borderline hypertension.\n\nAntenatal Hx - for EGA 40-3/7 weeks at delivery on at 2252. ROM occurred 5 hours PTD, yielding clear amniotic fluid, wiht terminal meconium at delivery. There was no intrapartum fever or other clinical evidence of chorioamnionitis. No intrapartum anitbacterial prophylaxis was administered. She proceeded to a cesarean section under epidural and spinal anesthesia, for non-reassuring fetal tracing.\n\nNeonatal course - NICU tema not in attendance at delivery. Infant received only tactile stim. Apgars 9 at one minute, 9 at five minutes. Infant has been well in regular nursery, with some fussiness in the past 12 hours. Tonight after an episode of crying, he was noted to be facially cyanotic by his parents. THis resolved spontaneously after a few moments. There was no apnea, respiratory distress, or abnormal movements noted. Subsequently he has been asymptomatic.\n\nPE\nvery well-appearing infant in no distress\nhr 105 rr 56 See Carevue\nBW 3425 g\nHEENT AFSF; non-dysmorphic; palate intact; no nasal flaring\nCHEST no retractions; good bs bilat; no adventitious sounds\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent; cord intact\nGU normal penile shaft with recent circumcision intact and healing; testes descended bilaterally\nCNS active, alert, resp to stim; axial and appendicular tone normal and symmetrical; MAE symmetrically; suck/root/gag itnact; EOM normal; no facial asymm; grasp symm\nINTEG normal\nMSK left forefoot adducted with prominence of head of 5th MT; insp/palp/ROM all ext otherwise within normal limits\n\nIMPRESSION\nTerm infant with\n1. Cyanotic episode following crying at 28 hours of age. Given the description of this event, its brevity and the fact that infant has been otherwise entirely asymptomatic, this is likely a benign event, possibly related to choking, vagal effect or breathholding following crying. Differential diagnosis includes immaturity of respiratory control, or much less probably, seizure or early manifestation of a systemic process such as infection. There has been no sustained cyanosis and the cardiac examination is normal.\n2. Left metatarsus adductus deformity\n3. Antenatal exposure to lyme disease, with history of adequate maternal treatment\n\nPLAN\n-We have admitted the infant for monitoring of respiratory status and feeding maturity. If he does not manifest further episodes, we will transfer back to regular nursery later today. Further investigations will be considered as indicated if another event occurs\n\nOB: Dr. \nPCP: . . Young\n\n" }, { "category": "Nursing/other", "chartdate": "2105-01-31 00:00:00.000", "description": "Report", "row_id": 1717381, "text": "1. in RA, color pink, jaundice, RR20-40's, BBS clear,\nequal, no retractions, no apnea, brady, desat or dusky\nepisode-please refer to flow sheet. continue to monitor-day\n.\n2. temp stable swaddled in open crib, waking ~q4h for\nfeedings, active and with cares.\n3. Parents here at 08 and 12n for feedings, Mom puts baby to\nbreast, referred to LC for assistance. Parents very\nconcerned, updated by Dr . continue parent teaching\nand support.\n4. on ampi, gent and acyclovir-continue meds and monitoring.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717376, "text": "1 RESP\n2 G&D\n3 Parents\n4 Sepsis\n\nNursing Progress Note:\n#1 - RESP: Remains in room air. Lungs clear and equal. No\nretractions. RR(20-40). O2Sats>95%. No spells thus far this\nshift. Last brady with desat ~6:45am. PLAN: monitor. Spell\ncount for discharge.\n#2 - G&D: Temps stable on off warmer. and active with\ncare. MAE. AFSF. Breastfeeding well. Bottled a twice early\nthis am. Wakes for feeds. Sleeping well between feeds.\n#3 - PARENTS: Updated at the bedside throughout the day.\nShown how to take a temp and change a diaper. Mom\nbreastfeeding. well.\n#4 - SEPSIS: Infant started on amp/gent/and acyclovir due to\nseveral spells earlier today. Head CT done - neg. CBC and\nblood culture sent. No shift. LP done - no meningitis. Cxt\npending. Continue to monitor closely.\n\nREVISIONS TO PATHWAY:\n\n 1 RESP; added\n Start date: \n 2 G&D; added\n Start date: \n 3 Parents; added\n Start date: \n 4 Sepsis; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717377, "text": "Nursing Addendum:\nEKG done - faxed over to for official . Electrolytes sent - 145/5.1/108/18, Ca 10.5, Phos 6.5, Mg 2.2, Bili 7.0/0.2. Baby breast feeding well. No further spells today. Continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2105-01-31 00:00:00.000", "description": "Report", "row_id": 1717378, "text": "Nursing NICU Note\n\n\n1. Resp. O/Pt remains in RA. NO apnea or desaturations noted\nthis shift as of yet. Please refer to flowsheet for\nremainder of shift. A/Resp status has appeared stable this\nshift thus far. P/Cont. to monitor for A/B and intervene as\npt needs. Cont. to monitor for evidence of resp distress.\n\n2. G/D. O/ Waking on own eager to feed (actively rooting and\neagerly sucking on pacifier). Latching on well during\nbreastfeeding. Coordinated suck/swallow/breathing reflex\nnoted while bottle feeding. A/Alt. in G/D. P/Cont. to\nsupport pt's growth and dev. needs.\n\n3. Parents. O/Parents in yest night. Parents are up to date\non pt's status and plan of care. Mother demonstrated good\nbreast feeding technique. Father giving mother verbal\nsupport. A/Parents are actively involved in pt's care.\nP/Cont. to support and educate parents.\n\n4. sepsis. O/Remains on Ampicillin, Gentamicin and Acyclovir\nPIV. Bld culture results neg to date. A/Potential for\nsepsis. P/Cont. to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-01-31 00:00:00.000", "description": "Report", "row_id": 1717379, "text": "Neonatology Attending Progress Note:\nDOl #3\npma 40 6/7 weeks\nremains in RA, RR=20-40's, no spells\nno murmur, HR=100-120;s, pink, slightly jaundiced\nEKG faxed to yesterday\n3320g ( 65g), ad lib feeds\ndstx=80s\nvoiding, passing stool\ncirc site heeling\nLytes: 145/5.1/108/18, ca=10.5, p-6.5, Mg=2.2\non amp, gent, acyclovir\n\nImp/Plan: full term infant with apneic spell with negative evaluation, r/o sepsis, monitoring for further spells\n--monitor for spells\n--head CT normal\n--EKG pending\n--HSV pending, continue acyclovir until PCR results back\n--continue amp and gent pending blood culture results\n--I updated family at bedside today\n" }, { "category": "Nursing/other", "chartdate": "2105-01-31 00:00:00.000", "description": "Report", "row_id": 1717380, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone, + suck +/= grasp\nface, trunk and thighs jaundiced\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717370, "text": "NICU NPN 0500\nBaby admitted to the NICU from NBN following an observed dusky episode by parents, following crying, which resolved spont. No further episodes noted. Please see attending note for history and details.\n\nVSS on arrival to the NICU. TEMP 98.5 AX, BP 79/40 53, HR 114, RR 47 SAT 100% IN ROOM AIR.\n\nRESP O: Lungs are clear, o2 sats 99-100% in room air. Occasionally looks slightly dusky around mouth, but sats remain 98-100%. No resp distress noted.\n\nCV O: No murmur, hr 90-120's. Color pink, mildly jaundiced. BP's stable.\n\nFEN O: Baby has been ad lib BF well. Per parents, baby may be given bottle for now, until mom's milk expresses. Voiding and stooling. Circ done yesterday, site unremarkable.\n\nDEV O: Baby is and active with cares. Mom noted baby to have a very fussy night. Will continue to give tylenol as ordered for circ.\n\nParenting O: Mom and dad in and updated at the bedside. Aware of plan of care, and possible transfer to NBN if continues to be benign.\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717371, "text": "NICU NPN ADDENDUM\nBaby had a brady to 61, and desat to 68, requiring bbo2, and vigorous stim to recover. NNP aware. CBC with diff and blood cx drawn, and plan to send baby to CT asap. Team to speak with parents.\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717372, "text": "Case Management Note\nChart has been reviewed and events noted. I wil place EIP & VNA options in record. I will cont to follow and assist w/any d'c planning needs along with team & family\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717373, "text": "2 loose stools\ndstx=68\n\nCSF with 3 WBC, 185RBC, diff pending. 73P, 55glucose\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717374, "text": "Neonatology Attending Update:\nDOl #2\nPMA 40 5/7 weeks\nhad a brady this am to 61, desat to 68% with apnea.\nno murmur, HR=80-120s\nwt=3285g\nWB=12.7, crit=50, plt 362, 49P0B\nvoiding\nImp/Plan: FT well appearing infant with apnea.\n--monitor for spells\n--head CT done\n--LP done and results pending, sent for herpes PCR as well as WBC, culture\n--amp, gent and acyclovir started\n" }, { "category": "Nursing/other", "chartdate": "2105-01-30 00:00:00.000", "description": "Report", "row_id": 1717375, "text": "Neonatology NP Procedure Note\nLumbar Puncture\nIndication: r/o meningitis\nParental consent in chart\nInfant given sucrose for pain management\n\nTime out observed to confirm patient and procedure\nInfant held in left lateral position\nlumbar-sacral area prepped and draped.\n22 gauge 1 inch spinal needle inserted at L4-5. ~ 2.5 ml clear CSF removed and sent to lab. Needle removed.\nInfant tolerated procedure well. No complications.\n" }, { "category": "Radiology", "chartdate": "2105-01-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 895027, "text": " 7:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with apnea/desaturations with unknown etiology\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN, \n\n INDICATION: Apnea and desaturations of unknown etiology, rule out hemorrhage.\n\n TECHNIQUE: Axial non-contrast CT scans through the brain were obtained. No\n previous studies are available for comparison.\n\n FINDINGS:\n\n The brain appears morphologically normal. The ventricles are normal in size\n and configuration. There is no shift of structures. No areas of increased\n density are evident within the brain or extra-axial spaces to indicate the\n presence of acute hemorrhage. Overall, -white matter differentiation\n appears preserved. There is limited visualization of the inferior cerebellum.\n\n The skull appears normal.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or cortical\n territorial infarction is identified. Followup imaging, and perhaps MRI, is\n recommended if signs persist.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-07-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 970934, "text": " 11:58 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for interval change of L apical pnthx and R pleu\n Admitting Diagnosis: PNEUMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p fall down stairs w/ L side rib fx and hemopneumothx,\n hospital day 4\n REASON FOR THIS EXAMINATION:\n please eval for interval change of L apical pnthx and R pleural effusion,\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with left-sided rib fractures and\n hemopneumothorax, evaluate for interval change of left pneumothorax and right\n effusion.\n\n COMPARISON: .\n\n CHEST, TWO VIEWS: Apical component of left pneumothorax is unchanged. Cardiac\n size, mediastinal and hilar contours are normal. Subtle interstitial\n opacification at the bases is unchanged and together with the unchanged small\n bilateral pleural effusions, likely represents mild interstitial edema.\n Multiple left rib fractures are again seen.\n\n IMPRESSION:\n\n Essentially unchanged radiographic chest: left apical pneumothorax, mild\n interstitial edema and bilateral small pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 970734, "text": " 9:00 AM\n CHEST (PA & LAT) Clip # \n Reason: comparison of hemopneumothorax from previous films\n Admitting Diagnosis: PNEUMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hemopneumothorax\n REASON FOR THIS EXAMINATION:\n comparison of hemopneumothorax from previous films\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Hemopneumothorax.\n\n Apical component of left pneumothorax has slightly decreased in size with\n visceral apical pleural line now just below the left third posterior rib.\n Small left pleural effusion is unchanged. Subtle pulmonary opacities in the\n left lung adjacent to rib fractures likely represent mild pulmonary contusion.\n New very subtle interstitial opacities in the lower lungs probably represent\n mild interstitial edema, accompanied by small right pleural effusion.\n\n IMPRESSION:\n 1. Decreasing left apical pneumothorax.\n 2. Minimal interstitial edema and new small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 970597, "text": " 6:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for acute ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p fall, +head trauma\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WWM SAT 7:43 PM\n external trauma L post parietal convexity, no intracranial injury\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST, , HOURS.\n\n HISTORY: Status post fall with external head trauma.\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n brain and reconstructed at stacked 5-mm increments. No intravenous contrast\n was administered.\n\n COMPARISON: None.\n\n FINDINGS: There is a subgaleal hematoma over the posterior left parietal\n convexity near the vertex with small locules of subcutaneous air consistent\n with laceration. The underlying calvarium is intact. The skull base and\n included facial structures likewise demonstrate no evidence of fracture. The\n included paranasal sinuses and mastoid air cells are clear. The globes are\n intact with lenses in place.\n\n Intracranially, the ventricles are midline and normal in size and\n configuration. The cortical sulci and subarachnoid cisterns are unremarkable.\n The matter-white matter interface is well defined. There is no\n intracranial hemorrhage or CT evidence of acute cortical stroke.\n\n IMPRESSION: External head trauma as above. No intracranial injury.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-16 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 970599, "text": " 6:56 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for acute intrathoracic/abdominal path, spin\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p fall down several stair, has multiple rib fx and left PNX\n REASON FOR THIS EXAMINATION:\n please evaluate for acute intrathoracic/abdominal path, spinal fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe SAT 7:52 PM\n small left hemopneumothorax, with fractures of left 3-7th posterolat ribs and\n xverse processes on the left of t5 and t6. Adjacent subcut air and\n parenchymal opacities, likley contusions. No other pathology noted.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old female status post fall down several stairs with known\n rib fractures and pneumothorax. Evaluate for traumatic pathology.\n\n Comparison is made to prior chest radiograph from same date.\n\n CT OF THE CHEST/ABDOMEN/PELVIS:\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest,\n abdomen, and pelvis with intravenous contrast only per trauma protocol.\n Coronal and sagittal reformations were evaluated.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is a small left pneumothorax\n with a minimal amount of slightly hyperdense fluid noted inferiorly suggestive\n of small hemothorax. Adjacent parenchymal opacities next to fractured left\n seventh and sixth protruding into the lung parenchyma are most consistent with\n pulmonary contusions. The lungs are otherwise unremarkable and the airways\n are patent to the subsegmental level. Heart and great vessels appear normal\n with no pericardial effusion identified. No pathologically enlarged lymph\n nodes are present.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, spleen,\n stomach, intra-abdominal bowel, pancreas, adrenal glands, and kidneys appear\n normal. No free air or free fluid is noted within the abdominal cavity. No\n pathologically enlarged lymph nodes are identified.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Intrapelvic bowel and urinary\n bladder appear unremarkable. There is a slightly prominent endometrial stripe\n within the uterus, likely related menstrual phase. The adnexa are not well\n visualized. There are multiple small phleboliths within the pelvic cavity. No\n free fluid or pathologically enlarged but lymph nodes are identified.\n\n BONE WINDOWS: Single fractures are identified along the lateral portion of\n the left third, fourth, and fifth ribs with more comminuted fractures\n involving the left sixth and seventh ribs which protrude into the lung\n parenchyma as noted above. Additionally, there are minimally displaced\n fractures involving the left transverse processes of T4, T5 and T6. Other\n (Over)\n\n 6:56 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for acute intrathoracic/abdominal path, spin\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n than benign hemangiomas within the T12 and much smaller in the T5 vertebral\n bodies, no other suspicious osseous lesions are identified.\n\n IMPRESSION:\n\n 1. Small left hemopneumothorax with parenchymal opacities adjacent to\n comminuted rib fractures, likely corresponding to pulmonary contusions.\n\n 2. Single fractures involving the left third to fifth ribs with more\n comminuted fractures involving the left sixth and seventh ribs and transverse\n process fractures involving the left T5 and T6 processes with questionable\n small fracture also involving T4.\n\n 3. Slightly prominent endometrium likely within normal limits in a\n menstruating female. Please correlate clinically with patient's stage of\n menstrual cycle.\n\n Findings were discussed with the trauma team shortly after image acquisition.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-16 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 970598, "text": " 6:47 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for cervical fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p fall down stairs, +head trauma, no neuro deficits, no h/o\n hyper flexion/extension; in c-collar\n REASON FOR THIS EXAMINATION:\n please evaluate for cervical fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WWM SAT 7:45 PM\n negative for cspine inj, l apical pntx again seen\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE C-SPINE WITHOUT CONTRAST, AT 19:08 HOURS.\n\n HISTORY: Status post fall downstairs with head trauma. No neurologic\n deficits.\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n cervical spine and reconstructed at stacked 2.5 mm increments utilizing bone\n and soft tissue window algorithms. Coronal and sagittal reformatted images\n were generated.\n\n COMPARISON: None.\n\n FINDINGS: The cervical spine is normally aligned. The vertebral bodies are\n intact. The disc spaces are well preserved. The prevertebral and other soft\n tissues of the neck are unremarkable. A small apical left pneumothorax is\n seen consistent with the previously acquired chest x-ray.\n\n IMPRESSION: No cervical spine trauma.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970596, "text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval fx, ptx, pna, uffison, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with R sided bruising and ttp\n REASON FOR THIS EXAMINATION:\n eval fx, ptx, pna, uffison, edema\n ______________________________________________________________________________\n WET READ: WWM SAT 6:43 PM\n L apical pntx with multiple left sided rib fxs\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 18:33 HOURS.\n\n HISTORY: Right-sided bruising.\n\n COMPARISON: None.\n\n FINDINGS: There is a prominent left apical pneumothorax with approximately 15\n mm of maximal visceral and parietal pleural separation at the apex. The\n trachea adn mediastinum remain midline. There is a markedly displaced\n segmental fracture involving the posterior aspect of the left seventh rib.\n Minimally displaced fractures posterolaterally of the left third through sixth\n ribs are also present. No definite effusion is seen. The cardiac silhouette\n is within normal limits for size. The right lung is clear. Vertebral body\n heights are preserved throughout the thoracic spine.\n\n IMPRESSION: Left apical pneumothorax with multiple left-sided rib fractures\n as detailed above. Results were immediately posted to the ED dashboard and\n relayed by phone to Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2101-07-16 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 970617, "text": " 11:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change, evolution of hemo/pneumo thorax in pt with\n Admitting Diagnosis: PNEUMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with R sided bruising and ttp\n\n REASON FOR THIS EXAMINATION:\n interval change, evolution of hemo/pneumo thorax in pt with multiple rib\n fractures after falling down stairs\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left pneumothorax, evaluate progress.\n\n The prior film was taken in supine position and the current in the upright\n position. Size of the pneumothorax is therefore difficult to evaluate but\n probably allowing for differences in position, has not changed substantially\n since the prior chest x-ray.\n\n Multiple rib fractures are again noted. A small left effusion is present.\n The right lung is clear.\n\n IMPRESSION: Allowing for changes in position, no significant change in size\n or pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-07-17 00:00:00.000", "description": "Report", "row_id": 1656282, "text": "nursing admit/progress note\n\npt is a 44 yo female who fell down 7 stairs while at work, landing and sliding down on back and striking head on banister. no LOC, no c/o sob/distress, only L sided chest pain. CT revealed sm. L hemo/pneumothorax, # rib fx's on L (w/ #7 signif displaced), assoc. likely pulm contusions, T5-6 trans. proc. fx's and possible T4 trans proc fx. to TSICU for observation.\n\nneuro: a+ox3, moving all extrem well. c/o mild to mod. L sided chest pain (rib fxs) on admit, able to move well, minimal splinting noted. epidural catheter placed by anesthesia for pain control (T7), supplemental dilaudid pca also initiated. pain much improved per pt w/ epidural, initial sensory level T6, infusion titrated to same level, currently up to 6cc/h bupivicaine after 4cc bolus. using pca effectively.\n\nresp: ls clear throughout, o2 sats stable 2l nc. denies sob/distress, taking deeper breaths, using i/s well.\n\ncv: hypotensive to 90s syst. w/ epidural, closely followed. extrem warm, pulses intact. lytes repleted prn. given bolus 1000 cc ivf after initial epidural bolus w/ insertion. nsr, 80s, no ectope.\n\ngi: npo, belly soft/nt/nd.\n\ngu: foley placed, large amts clear yellow urine.\n\nid: afebrile, wbc stable.\n\nskin: small abrasion to occiput, area cleansed w/ ns, left ota. draining sm amts serosang drainage.\n\nsocial: husband in last eve, supportive. plans to visit today.\n\na/p: s/p fall, mult rib fx's, pneumotx. per cxr, hemo/pneumotx stable. pain better controlled w/ epidural and pca. pt able to use i/s and deep breathe. likely to transfer to floor today if pain control remains adeq, barring any issues.\n" }, { "category": "ECG", "chartdate": "2101-07-16 00:00:00.000", "description": "Report", "row_id": 228355, "text": "Sinus rhythm. Incomplete right bundle-branch block. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2137-08-28 00:00:00.000", "description": "Report", "row_id": 1682067, "text": "Case Management Note\nReferral called to Health VNA (/fax ) and they have home visit available for Sunday . Will need referral faxed to above # at d'c. All in agreement w/plan. I will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-28 00:00:00.000", "description": "Report", "row_id": 1682068, "text": "Fellow PE Note\nGen: awake, , active\nHeent: afof, MMM, o/p clear\nCor: RRR, no murmur\nLungs: cta b/l, no retractions\nAbd: soft, nt, nd, +bs\nExt: no c/c/e, warm, good cap refill, moves all ext.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-28 00:00:00.000", "description": "Report", "row_id": 1682069, "text": "3. breastfeeding or taking BM/E20 30-60cc q4h po well, abd\nsoft, exam benign, no spits, voiding and passing stool.\n4. temp stable (borderline) swaddled in open crib with\nbrother, active and with cares. circ done this am by\nDr , site red, swollen, very sm bleeding, 2x2 with\npetrolatum applied with diaper changes, voided post circ.\nreceiving tylenol q6h. passed car seat screen this am, VNA,\npedi appts set up, please see chart for details, potential\ndc tomorrow.\n5. here most of day, reviewed feeding, baby care,\nsigns of illness, shown circ care. more independent\nwith care. continue dc teaching and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-29 00:00:00.000", "description": "Report", "row_id": 1682070, "text": "npn 1900-0700\n\n\n3: nutrition\ncw 2115gms up 40gms. continues on a min of 80cc/kilo/day of\nbm/e 20. infant waking q 4 hours and taking 50-55 cc thus\nfar this shift. tolerating feeds well. no spits thus far\nthis shift. abd soft with no loops. voiding and stooling.\nstool hem neg. continue to encourage po feeds.\n\n4:dev\ntemps stable in an oac. co-bedded with brother. and\nactive with cares. sleeps well inbetween. brings hands to\nface. sucks vigorously on pacifier. circ site clean. small\namount of blood on gauze with each diaper change.\ncontinue to monitor site for bleeding.\n\n\n5: \ndad called x's 1. updated by this rn. asking appropriate\nquestions. preparing for possible dc in the am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-29 00:00:00.000", "description": "Report", "row_id": 1682073, "text": "Nursing Discharge Note:\n\n\nInfant appears pink, well perfused. Breathing comfortably in\nRA; O2 sats WNL. Lung sounds clear/=. No retractions. No\nspells. TF min 80cc/kg/day; Enfamil 20. Infant bottled 60cc\nthis morning and breastfed x1 for about 15 min this\nafternoon. Infant eager at breast with strong suck. Infant's\nabdomen is soft, NT, ND, +BS, no loops. Infant is\nvoiding/stooling. No spits. Discharged home on Trivisol.\nCirc site intact; minimal drainage and swelling. Treated\nwith vaseline gauze. Tylenol given x1. Cobedded in OAC with\nbrother. Infant sleeps well between cares; wakes for\nfeedings q 2-4 hrs and remains A/A throughout cares. MAE.\nAFSF. Calms with pacifier. AGA. happy to be bringing\nbabies home. Appear very loving and comfortable caring for\ninfants. Discharge teaching completed and VNA referral\ndone. properly placed infant in carseat, discharged\nhome.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-29 00:00:00.000", "description": "Report", "row_id": 1682071, "text": "Fellow Discharge Physical Exam Note\nGen: awake, , active\nHeent: afof, +RR b/l, TMs clear, nares patent, o/p clear, MMM\nCor: RRR, no murmur\nLungs: cta b/l, no retractions\nAbd: soft, nt, nd, +bs, no hsm, no masses, umbilical stump dry and no significant erythema or drainage\nExt: neg o/b, fem pulses 2+, warm, cap refill instant\nNeuro: good tone, moves all extremities equally b/l, no focal deficits on exam\nGU: circumcised male, testes down b/l, circ site c/d/i\nSkin: no lesions\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-29 00:00:00.000", "description": "Report", "row_id": 1682072, "text": "Neonatology Attending Progress Note\n\nNow day of life 6, CA weeks.\nIn RA with RR 40-50s - very stable with no apnea/bradycardia.\nCVS - HR 140-170s BP 79/33 49\n\nWt. up 40gm to 2115gm on ad lib feedings of MM - took in 136ml/kg/d plus breastfeeding.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill discharge to home today.\nFU with Dr. scheduled for tomorrow at 4:15.\n\nVNA will also follow over the weekend.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-23 00:00:00.000", "description": "Report", "row_id": 1682049, "text": "NP1500-2300\n\n\n#1 RESP O: Infant remains on RA, 02 sats >95%, BBS equal and\nclear, breathing comfortably, no desats or spells. A: Stable\nRESP P: cont to assess for increased wob. Monitor and\ndocument all spells.\n#2 SEPSIS O: Infant remains on AMpi and Gent. CBC shows\nneutropenia, plan for repeat in am. Temp stable, alert and\nactive, no signs of sepsis. A: R/O Sepsis P; cont to assess\nfor signs of infection, cont with antibiotics.\n#3 FEN O: Infant remains on TF 60cc/k/day of D10W. First\nfeeding given of PE20 took 15c well. Abd soft and\nnondistended, good bowel sounds, voiding, dry diaper at\n2100. D/S 60's. A: ALt in FEN P:Cont to assess for feeding\nintolerence, wt q day, maintain IVF as ordered.\n#5 PARENTING O: Mom and Dad in to visit, asking appropriate\nquestions and updated on infant's progress. P: cont to\ninform and support family as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-24 00:00:00.000", "description": "Report", "row_id": 1682050, "text": "NPN 2300-0700\n\n\n1. Resp: Infant remains in RA with O2 sats = 97-100%.\nRR=30-50's. No retractions. LS clear. No spells or\ndesats.\n\n2. Sepsis: Bld cx remains neg to date. Infant continues\nreceiving ampi and gent as ordered.\n\n3. FEN: WT=2175gms (down 35gms). TF=60cc/k/day. Infant\nis currently receiving D10W at 30cc/k/day via piv. Enteral\nfeeds are BM/PE20 at 30cc/k/day. (See flowsheet for po\nintake). D/S = 67. No spits. Plan is to continue weaning\nIVF as tol. U/O for past 8hrs was 4.5cc/k/hr. No stool.\nAbd is soft and round with active bs. Abd girth = 25cm.\n\n4. G&D: Infant is alert and irritable with cares. Uses\npacifier to comfort self. Sleeps well between cares. Temps\nstable swaddled on off warmer. AFSF. AGA.\n\n5. Parents: No contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-24 00:00:00.000", "description": "Report", "row_id": 1682051, "text": "Neonatology Attending Progress Note\n\nNow day of life 1 for this 34 week testation twin B.\nRR 30-50s - no apnea and bradycardia.\n\nHR 120-140s BP 61/28 39\n\nWt. 2175 down 35gm on 60ml/kg/d TF - 30ml/kg/d of MM or PE - feedings going well by bottle/breast starting.\nNormal urine and stool ouput.\n\nDS 63-67\nBili 4.3\n\nID - on amp and gent\ncbc reopeat wbc 7,800 30P 0B 57L 9M\nplat 298,000 Hct 40.5%\n\nAssessment/plan:\n34 week gestation infant doing very well.\nWill advance breast and bottle feeding - wean IV fluids.\nAntibiotics to continue pending culture results.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-23 00:00:00.000", "description": "Report", "row_id": 1682046, "text": "Neonatology Attending Admit Note:\n\n34 week twin B infant brought to NICU for issues of prematurity.\n\ninfant born to a 30 year old G1P0 mother negative, RPR NR, blood type A positive, antibody negative, and rubella immune. EDC . PRegnancy noteable for:\n1) spontaneous di/di twins\n2) PTL with cervical shortening at 24 6/7 weeks, received betamethasone x2, magnesium, bed rest. resolved.\n3) today presented in labor. unknown GBS, no maternal fever, no maternal antibioitcs, ROM at delivery. Due to late gestational age, elected to deliver twins.\n\ntwin emerged by C/S at 7:14 on . Apgars of 8 (1min) and 9(5min). active, well appearing, dried, suctionned.\n\nbrought to NICU for further care.\n\nPE: vital signs noteable for mild tachypnea. Wt=2215g (50-75%), L=45.5cm (50%), HC=32cm (50-75%)\nwell appearing, AFOF, palate intact, RR deferred, normal S1S2, no murmur, breath sounds slightly coarse, mild ic/sc retx, abdomen soft, nontender, nondistended, ext well perfused. testes descended bilaterally, small bruised area over right testes, spine intact. hips stable. symmetric and normal tone and activity.\n\nImp/Plan: Premie AGA twin B, well appearing\n--will obtain CBC/diff and blood culture, treat with amp and gentamicin if abnormal diff, positive blood culture, and/or persistent respiratory distress.\n\n--monitor respiratory status closely\n\n--monitor glucose, begin IVF. NPO for now. consider feeds later today if remains stable\n\n--monitor for hyperbilirubinemia, apnea of prematurity\n\n--will need to meet with family and provide update since initial and last meeting was at much younger gestational age and issues/outcomes are dramatically different now.\n\n--I briefly updated family in the delivery room.\n\nOb: Dr. \nPedi: unknown\n" }, { "category": "Nursing/other", "chartdate": "2137-08-23 00:00:00.000", "description": "Report", "row_id": 1682047, "text": "CAse Management Note\nChart has been reviewed to date and events noted. I will be placing EIP & VNA options in record. I will provide clinical updates to Network Health as requested. Will cont to follow and assist w/any d'c planning needs.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-23 00:00:00.000", "description": "Report", "row_id": 1682048, "text": "NICU NSG Admission Note\nO: Baby \"\" , twin #2 admitted to NICU at ~0740 after C/S delivery at 34 wk. gestation with apgars 8, 9. Mom is 30 y.o. G-1 P-0->2. (please see above note for maternal hx) Infant pink and vigorous on admission. Wt-2215gms. Placed on servo control warmer with cardio-resp. and 02 sat monitors on, alarms set and audible. VS noted on flowsheet. CBC and BC sent. Initial D/S=39. PIV placed in R hand and D10W at 60cc/kg=5.5cc/hr commenced. Repeat D/S=63, then 66. Vit. K and erythromycin given. IV Gentamycin and Ampicillin given per NICU protocol. Currently Temps stable on servo, appropriate tone and activity. HR-130's-150's, no murmur, brisk cap refill. BP means 38-45. RR 30's-60's with easy WOB. Sats 95-100 in RA. Breath sounds are clear and =. Abd. flat with active BS. NPO at present. Voided X 1 since admission. No stool. Dad in several times with grandparents. Mom in on strecher on way to floor. Both parents updated and questions answered.\nA: 34+ week, twin #2, doing well at present\nP: Close observation and monitoring for resp. stability, hypoglycemia, s/s sepsis, hyperbili, etc. Follow daily wts. Keep parents updated and informed.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-25 00:00:00.000", "description": "Report", "row_id": 1682056, "text": "Nursing Progress Notes.\n\n\n#2 O: 48 hour rule out sepsis complete. A: Cultures\nnegative. P: Problem resolved.\n#3 O: Total fluids increased to 80cc/kg/day of BM/PE20.\nFeeds offered every 4 hours. Baby also attempting to\nbreastfeed on before each feeding. Occasional spits,\nabdomen soft, bowel sounds active, no loops, voiding well,\npassing meconium. NG placed prior to 1700 feeding, only\nrequired 3.5cc feeding by gavage. A: Learning to PO feed.\nP: continue to encourage breastfeeding and suppliement with\nbottle and gavage feeding as needed.\n#4 O: Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares, swaddled and with\nboundaries in an open crib. Baby wakes for feeds and takes\nhis paicifier when offered. A: Appropriate for age. P:\nContinue to support development.\n#5 O: Parents up to visit and feed baby at each feeding.\nMother requires assistance with cares and feeding. A:\nInvolved family. P: Continue to keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-25 00:00:00.000", "description": "Report", "row_id": 1682057, "text": "NNP Physical Exam\nPE: pink, jaundiced, breath sounds clear/equal with easy WOB, no murmur, abd soft, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-26 00:00:00.000", "description": "Report", "row_id": 1682058, "text": "Neonatology Attending Progress Note\n\nNow day of life 3, CA 4/7 weeks.\nIn RA with RR 30-50s.\nNo apnea and bradycardia.\nHR 130-150s BP 69/39 50\n\nWt. 2110gm down 30gm ordered for 80ml/kg/d of MM or PE - feedings going well by bottle, breastfeeding a little slower - took in 99ml/kg/d\nNormal urine and stool output\nDS 73\n\nBili 7/0.4\n\nAssessment/plan:\nVery nice progress continues.\nWill transition to E20 in addition to breastmilk.\nLactation consultation planned.\nFamily meeting to be scheduled today.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-26 00:00:00.000", "description": "Report", "row_id": 1682059, "text": "3. taking E20/BM adlib amts, 25-45cc ~q3-4hs, abd exam\nbenign, no spits, voiding and passing stool, not latching on\nwell to breast feed, Mom has met with LC. will continue to\noffer assistance.\n4. temp stable swaddled in open crib with brother, active\nand with cares, waking for feedings. continue to\nsupport growth and development.\n5. Mom here for all feedings, very loving, plan for family\nmeeting this afternoon, continue dc teaching.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-27 00:00:00.000", "description": "Report", "row_id": 1682060, "text": "NPN 7p-7a\n\n\nFen: Wt 2.105kg (-5gms). Conts on adlib demand feeds of\nbm/e20. Waking q3-4hrs for feeds. Po'ing 30-35cc. Intake for\n24hrs 88cc/kg +bf. Abd soft. Active bs. Stool x2 thus far.\nVoiding with each diaper change. No breast feeding so far\nthis shift. cont with current plan.\n\nDev: Temp stable swaddled in open crib. and active\nwith cares. Sleeps well between. Waking on own for feeds.\nSlightly uncoordinated with po feeds. Cont to support\ndevelopmental milestones.\n\nParenting: Mom and Dad in this evening. Updated at bedside.\nIndependant with temp and diaper. Cont to support and updte.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-24 00:00:00.000", "description": "Report", "row_id": 1682052, "text": "Nursing progress notes.\n\n\n#2 O: Baby remains on IV ampi and gent. Cultures pending.\nA: On 48 hours rule out sepsis. P: follow culture results.\n#3 O: Baby feeding ad lib with BM20 or PE20. Baby feeding\non demand or 4 hours. No spits, girth stable, abdomen\nsoft, bowel sounds active, no loops. Voiding well, no stool\nyet. Baby breastfed fairly well for the first time,\nlatching and taking intermittant sucks for 5 to 10 min\nbefore falling asleep. No busts of sucking occured. When\nbottle feeding baby is slow but with no uncoordinated\nsucking or choking. IV of D10W heplocked at 1300. D/stix\nthis morning 63. A: Learning to PO feed and breastfeed. P:\nContinue to encourage breastfeeding and bottlefeed as\nnecessary. Check D/stix off IV fluids.\n#4 O: Temp stable on off warmer. Baby wakes quietly at\nfeeding times and sleeps well between cares. Pacifier taken\nwhen offered. A: Appropriate for age. P: continue to\nsupport development.\n#5 O: Parents up to visit and feed baby this morning.\nFather held and fed baby for the first time with assistance.\n Mother back several times to visit and feed baby \nthe day. A: Involved family. P: Continue to keep informed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-24 00:00:00.000", "description": "Report", "row_id": 1682053, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant bundled on open warmer; room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nCHest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; femoral pulses+2\nABd: soft; no masses; + bowel sounds; cord on/drying\nExt: moving all\nNeuro: symmetric tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2137-08-25 00:00:00.000", "description": "Report", "row_id": 1682054, "text": "npn 1900-0700\n\n\n2: sepsis\ninfant remains on antibiotic therapy for 48 hours. no signs\nand symptoms of infection noted. continues on amp and gent.\ncontinue to monitor for changes in pt. plan to dc\nantibiotics if no growth present.\n\n3: nutrition.\ninfant current weight 2140gms down 35gms. total fluids\nremain ad lib. infant taking 25cc with each feeding and bf\nx's 1. infant latches on but only takes a few sucks. mom\nplans to both breastfeed and bottle feed at home. infant abd\nexam benign. voiding and stooling. abd soft with no loops.\nstable girths. one small spit thus far this shift. continue\nwith plan of care.\n\n4: dev\nreceived infant on an off warmer. infant moved to oac.\nco-bedded with brothers. infant and active with cares.\nsleeps well inbetween. brings hands to face. sucks\nvigorously on pacifier. waking for some feedings. continue\nto monitor for developmental milestones.\n\n5: Parenting\nmom and dad in for 2100 care. mom and dad both active in\ncare. mom feeding infant and dad taking temp and changing\ninfant. loving and involved family.asking appropriate\nquestions. continue to encourage po feeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-25 00:00:00.000", "description": "Report", "row_id": 1682055, "text": "Attending Note\nDay of life 2 PMA 34 \nin room air RR 20-60 sat 99-100%\nHr 120-170's pink slightly ruddy\nBP 63/39 mean 48\ns/p amp/gent for 48 hours\n2140 down 35 ad lib took 63 cc/kg/day of PE 20 or BM 20 cal/oz\none spit\nD stick 73\n and active\nawakes for cares\n\nImp-stable making progres\nwill continue to monitor for spells\nwill have a minimum of 80 cc/kg/day\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-27 00:00:00.000", "description": "Report", "row_id": 1682061, "text": "Neonatology Attending Progress Note\n\nNow day of life 4, CA 5/7 weeks.\nIn RA with RR - 30-50\nNo apnea and bradycardia.\nCVS - HR 120-130 BP 63/50 52\n\nWt. 2105gm down 5gm on ad lib feedings - took in 88ml/kg/d plus breastfeeding - feedings mostly by bottle well tolerated.\nNormal urine and stool output.\n\nLactation consult with last night.\n\nDischarge teaching in progress.\n\nAssessment/plan:\nDoing well.\nWill continue with current management.\nHearging screen, car seat test and Hep B planned for today.\nCirc to be scheduled.\n will be the primary pediatrician.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-27 00:00:00.000", "description": "Report", "row_id": 1682062, "text": "Fellow Physical Exam Note\nGen: awake, , active\nHeent: afof, mmm, o/p clear\nCor: RRR, no murmur\nLungs: cta b/l\nAbd: soft, nt, nd, +bs, no hsm\nExt: no c/c/e, 2+ pulses, warm, good cap refill, moves all ext = b/l\nGU: nl male, testes down b/l\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-27 00:00:00.000", "description": "Report", "row_id": 1682063, "text": "Nursing note\n Parents attended Infant cpr class. Both parents participated in class and practiced on the mannikin. REviewed infant cpr, choking and back to sleep positioning. Parent watched video and handouts given. Parent stated an understanding of the info reviewed and denied any other questions.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-27 00:00:00.000", "description": "Report", "row_id": 1682064, "text": "NICU Nursing Progress Note\n\nNUTRITION\nO: Waking every 2-4 hrs to feed and breastfeeding\ninconsistently well. Supplemented with bottled BM and infant\ntaking 15-20cc after BF. Abd exam benign. Voiding andpassing\nheme nerg stool.\nA: Slower to BF, but overall taking good volumes.\nP: Monitor weight progression.\n\nDEVELOPMENT\nO: Temp 97.5 in open crib. Better with hat on and double\nblanket. Active and with cares. Tone wnl.\nA: Appropriate behavior.\nP; Support development.\n\nPARENTING\nO: Mom discharged today, but stayingovernight\nin parents' room. Independent in infant's care. Handles\ninfant well for BF. Parents took CPR today.\nA: Involved parents.\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-08-28 00:00:00.000", "description": "Report", "row_id": 1682065, "text": "NPN:\n\nRESP: RA. RR=30-40s. BBS =/clear. No A&Bs over past 24 h.\n\nCV: No murmur. HR=130-150s. BP=81/40 (53). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=2075g (- 30g). TF=min 80cc/kg/d (= 29cc BM/E-20 q 4 h). Intake yesterday 72cc/kg/d. Bottled well for 60cc w/good coordination. Tolerating feeds well w/o spits. Abd benign. Voiding qs; no stool since yesterday.\n\nBILI: Bili 7.0/0.4 on ; Bili pending.\n\nG&D: CGA=34 wk. Temp 97.6(Ax) -> placed under warming light for 30 min. Swaddled w/hat on and covered w/two blankets. Demanding fdgs. Active and w/good tone. Resting well. Carseat test to be done. Circ planned for today (0900). Anticipated discharge on .\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2137-08-28 00:00:00.000", "description": "Report", "row_id": 1682066, "text": "Neonatology Attending Progress Note\n\nNow day of life 5, CA 6/7 weeks.\nIn RA with RR 40-60s\nHR 130-150s 81/40 53\n\nWt. 2075 down 30gm on ad lib feedings - breastfeeding and took in 72ml/kg/d bottle and breastfeeding improving\nNormal urine and stool output.\n\nCirc performed this morning.\n\nBili 8.1\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management.\nPossible dc to home tomorrow.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2157-03-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 953921, "text": " 9:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? subdural hematoma or other bleed\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD s/p stenting with multiple falls and mental status\n changes\n REASON FOR THIS EXAMINATION:\n ? subdural hematoma or other bleed\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple falls and mental status changes.\n\n COMPARISON: None.\n\n FINDINGS: No intracranial mass, hemorrhage, shift of normally midline\n structures, or evidence for acute minor or major vascular territorial infarct\n is apparent. Moderate subcortical and periventricular white matter changes\n are consistent with chronic small vessel infarction. Prominence of the\n caudate head on the right is noted, which narrows the frontal of the\n right ventricle. The visualized portions of the mastoid and paranasal sinuses\n appear unremarkable. Surrounding osseous structures are within normal limits.\n\n IMPRESSION: No evidence of intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 953907, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with nstemi and and sob\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST.\n\n CLINICAL HISTORY: 78-year-old man with non-ST elevation MI and shortness of\n breath. Assess for interval change.\n\n Comparison made to prior study dated .\n\n FINDINGS: A single portable AP view of the chest was obtained on .\n The cardiac silhouette is mildly enlarged. There are increased interstitial\n markings bilaterally, suggestive of pulmonary edema. Small left pleural\n effusion. No evidence of pneumothorax.\n\n IMPRESSION: Findings suggestive of pulmonary edema, without appreciable\n interval change. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-03-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 953780, "text": " 8:07 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chf exacerbation\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with nstemi and SOB\n\n REASON FOR THIS EXAMINATION:\n chf exacerbation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:38 A.M. ON .\n\n HISTORY: MI and increasing shortness of breath.\n\n IMPRESSION: AP chest compared to 1:58 a.m.\n\n Moderately severe pulmonary edema has worsened. Mild cardiomegaly and small\n right pleural effusion have increased. Small left pleural effusion unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-03-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 953753, "text": " 1:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with nstemi and SOB\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:58 A.M., .\n\n HISTORY: MI and shortness of breath.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Mild pulmonary edema, mild cardiomegaly, and small left pleural effusion\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-03-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 955465, "text": " 11:48 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for LLL infiltrates.\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with nstemi and and sob\n\n REASON FOR THIS EXAMINATION:\n Please assess for LLL infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old male with NSTEMI and shortness of breath, for\n evaluation for left lower lobe infiltrate.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPHS: There is stable cardiomegaly. There has\n been interval improvement in pulmonary edema. There are persistent small\n pleural effusions, greater on the left. There is ill-defined area of opacity\n in the left retrocardiac region likely representing subsegmental atelectasis.\n\n IMPRESSION: Interval improvement in pulmonary edema. Persistent small\n bilateral pleural effusions, greater on the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-03-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 955024, "text": " 3:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pre-op eval\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with dementia, CAD, severe AS, MAT/afib plan for Aortic valve\n replacement\n REASON FOR THIS EXAMINATION:\n pre-op eval\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 78-year-old with dementia, mental state change.\n\n COMPARISON: CT .\n\n FINDINGS: No mass, hemorrhage, shift of normally midline structures or\n evidence of territorial infarct is apparent. Moderate subcortical and\n periventricular white matter changes are consistent with chronic small vessel\n infarction. Visualized portions of the mastoid and paranasal sinuses\n demonstrate no abnormality. The osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION: No acute process identified. Study is generally unchanged from\n previous dated .\n\n" }, { "category": "Radiology", "chartdate": "2157-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 954256, "text": " 10:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pulmonary oedema.\n Admitting Diagnosis: NON-ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with nstemi and and sob\n\n REASON FOR THIS EXAMINATION:\n Please assess for pulmonary oedema.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, 10:43 A.M.\n\n INDICATION: NSTEMI. Shortness of breath. Assess for pulmonary edema.\n\n FINDINGS: Compared with , there is now increased diffuse pulmonary\n edema. No obvious confluent infiltrates are seen. There is probably a small\n left pleural effusion.\n\n IMPRESSION: Increased pulmonary edema.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-03-06 00:00:00.000", "description": "Report", "row_id": 1353182, "text": "CCU Nursing Progress Note\nS-\"I quess I must of had a bad dream\"\nO-Neuro alert and oriented x3, pleasant and cooperative. Received resperiodol at HS and slept intermittantly during the night. Awoke once and was calling out, forgetting he was in the hospital.\nCV-Remains in MAT with HR 100 up to 130's, lopressor at 75mg TID with fair effect on rate. SBP stable 100's.\nResp-O2 at 2l np with good sats but easily gets SOB with minimal activity with rr 30's, O2 sat did drop to 89% during calling out episode and O2 increased to 4l np. Exp wheezes with BBR improved at night progressed.\nID afebrile with elevated WBC 15.4\nGU-foley present with fair urine output 20-30cc/hr. BUN/CR 61/1.7 post cath contrast of 200cc.\nGI-appetite good, thirsty last evening asking for water with mouth dry\nSkin-right groin intact without bleeding.\nAccess- 2PIV\nSocial no calls from family. Social service consult on Monday.\nCode Status-Full.\nA/P-NSTEMI inf/lat with succ 4 stents to LAD/RCA leisons. MAT persist despite lopessor EP consult to discuss possible ablation.\nCOntinue to increase lopressor dose aggresively and possible start calcium channel blocker? CXR to re-evaluate CHF with O2 requirements over night. Continue to keep pt and family aware of POC as discussed in mutli disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2157-03-04 00:00:00.000", "description": "Report", "row_id": 1353179, "text": "CCU Nursing Progress Note\nS-\"I feel too restained with all of these rules.\"\nO-Neuro alert and oriented x3 upon arrival from the cath lab. Very anxious, very talkative/perseverating/flight of ideas. Difficulty lying still with sheaths in place. Received ativan .5mg po at 1430. At 1600 found pt removed all EKG leads, PIV and hosp , dissoriented to time/place and reason for admit. Continued with confusion for next 3 hours, removing leg imobilizer and trying to get OOB. Restraint ordered for 4 side rails/bed alarm on. Freq checks by co-worker.\nCV-Remains tachycardic 120-130's MAT unresponsive to lopressor po/IV SBP 100-130. Right fem sheaths removed at 1500 with small amout of oozing no hematoma, pedal pulses at palpable feet cool/pale.\nResp-SOB at rest rr 30's LS exp wheezes u pper lobes with rales bilaterally. O2 sats on adm 87% on 4l np increased to 6lnp. After diuresis decreased O2 back to 4l np. Occ NPC.\nID afebrile with elevated WBC 16.\nGU-foley draining well after receiving lasix at 1100, total diuresis 2.5liters.\nGI-appetite good, no n/v, one moderate formed BM OB-.\nSOcial-married with 2 grown children at home. Wife called and spoke with MD, unable to come in because no one to drive wife? WIll have social service see pt to evaluate home.\nA/P-inferior NSTEMI s/p LAD/RCA BMS x4. Elevated filling pressures responed well to lasix. Confusion after ativan. Resperidol at HS. Continue to reorient freq with pt checks q1hr by co worker, 4 side rails up/bed alarm on. Continue to keep pt/family aware of POC as discussed in multi disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2157-03-05 00:00:00.000", "description": "Report", "row_id": 1353180, "text": "Nursing Progress Note\n11 pm - 7 am\nLAD/RCA BMS / CHF\nReceived patient oriented times one...several attempts made to re-orient the patient but patient without short term memory. Bedrails up and bed alarm on for patient safety. Patient awake and looking around room most of night. Resperidol .5 mg without affect. Became acutely agitated and anxious at 0500 ..intolerant to EKG/BP cuff ..attempting to climb out of bed \" to go home. \". DR. in to evaluate. Haldol 2.5 mg iv times one, with subsequent good affect.\nCV HR 120-150's..MAT ..SBP 90-100's/40-50's...Sudden drop in HR after haldol given. Denies CP or SOB.\nResp on 4l NP ..Lungs with cx's 1/2 up bilat ..non prod cough...\nGI/GU urine output per flowsheet. 2L negative at midnight.\nRate Control difficult due to borderline BP\n? Esmolol attempt\n? Haldol qhs\n" }, { "category": "Nursing/other", "chartdate": "2157-03-05 00:00:00.000", "description": "Report", "row_id": 1353181, "text": "Nursing Progress Note\n\nS:\" When am I going home?\"\n\nO: Please see flow sheet for objective data. Tele remains in MAT with SBP>100. Lopressor dose ^'d to 75mg TID. R groin is C&D without evidence of hematoma. Distal pulses are palpable. Echo done.\n\nResp: Conts to have rales ^^. O2 sats >95%. O2 weaned down to 2l NP.\n\nNeuro: Pt alert this am. Easily reoriented to surroundings and events. Responding appropriately to questions. OOB to chair with minimal assitance.\n\nGI/GU: Appetite is good. Abd is soft with bowel sounds present. Foley is draining CYU. Creat ^'d to 1.7. lasix held today. Goal is negative 500cc.\n\nSocial: Pt spoke with wife today over phone she is not able to get here. Pt is very concerned about ride home.\n\nA&P: 78yo man with NSTEMI and BMS's to LAD and RCA c/b MAT and CHF. Cont to titrate lopressor as tolerated. Advance activity as tolerated. Cont with POC.\n" }, { "category": "Nursing/other", "chartdate": "2157-03-04 00:00:00.000", "description": "Report", "row_id": 1353178, "text": "78yr male with hx HTN and bladder CA, admitted from OSH with non-STEMI. Developed SOB with probable CHF this AM. Taken to cath lab for RCA and LAD stent placement. Started on Atrovent nebs prn. BS decreased.\n" }, { "category": "Echo", "chartdate": "2157-03-11 00:00:00.000", "description": "Report", "row_id": 84372, "text": "PATIENT/TEST INFORMATION:\nIndication: atrial fibrillation, pre-cardioversion\nHeight: (in) 69\nWeight (lb): 162\nBSA (m2): 1.89 m2\nBP (mm Hg): 100/70\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 16:12\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. Mild spontaneous echo contrast in the body of the LA.\nGood (>20 cm/s) LAA ejection velocity. Definite thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Mild spontaneous echo contrast in\nthe body of the RA. No mass or thrombus in the RA or RAA. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Cannot exclude AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was monitored by a nurse throughout the\nprocedure. Local anesthesia was provided by benzocaine topical spray. The\npatient was sedated for the TEE. Medications and dosages are listed above (see\nviscous lidocaine. No TEE related complications.\n\nConclusions:\nThe left atrium is dilated. Mild spontaneous echo contrast is seen in the body\nof the left atrium. A definite thrombus is seen in the left atrial appendage\n(1.0 x1.0 cm, mobile). The right atrium is dilated. Mild spontaneous echo\ncontrast is seen in the body of the right atrium. No mass or thrombus is seen\nin the right atrium or right atrial appendage. No atrial septal defect is seen\nby 2D or color Doppler. Overall left ventricular systolic function is\ndepressed. There are complex (>4mm) atheroma in the aortic arch. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta. The aortic valve is\nbicuspid. The aortic valve leaflets are severely thickened/deformed. There is\nsignificant aortic valve stenosis (0.8 cm squared by planimetry). No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. Mild\n(1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nImpression: Mild left and right atrial sponteous echo contrast with a 1 cm x 1\ncm thrombus in the left atrial appendage. Significant aortic stenosis with a\nbicuspid aortic valve. Complex atheroma in the descending aorta and aortic\narch.\n\n\n" }, { "category": "Echo", "chartdate": "2157-03-05 00:00:00.000", "description": "Report", "row_id": 84373, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 100/68\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 10:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No LA mass/thrombus (best excluded by TEE).\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderate-severe\nregional left ventricular systolic dysfunction. No LV mass/thrombus.\nTrabeculated LV apex. TDI E/e' >15, suggesting PCWP>18mmHg.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - akinetic; mid inferoseptal - akinetic;\nbasal inferior - hypo; mid inferior - akinetic; basal inferolateral - hypo;\nmid inferolateral - akinetic; anterior apex - akinetic; septal apex- akinetic;\ninferior apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS (AoVA\n0.8-1.19cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Calcified tips\nof papillary muscles. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). Left ventricular wall\nthicknesses and cavity size are normal. There is moderate to severe regional\nleft ventricular systolic dysfunction with near akinesis of the distal 2/3rds\nof the inferior wall, septum and distal half of the anterior wall and apex. No\nmasses or thrombi are seen in the left ventricle, but the apex is heavily\ntrabeculated. Tissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with\nmild global free wall hypokinesis. The ascending aorta is mildly dilated. The\naortic valve leaflets are moderately thickened. There is moderate to severe\naortic valve stenosis (AoVA 0.9cm2). Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild to moderate (+) mitral regurgitation is seen. There is mild pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Extensive regional left ventricular systolic dysfunction c/w\nmultivessel CAD or other diffuse process. Moderate to severe aortic valve\nstenosis. Pulmonary artery systolic hypertension. Mild-moderate mitral\nregurgitation.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2157-03-04 00:00:00.000", "description": "Report", "row_id": 227939, "text": "Sinus tachycardia. Significant Q waves in leads III and aVF with ST segment\nelevations and terminal T wave inversions. Reciproical ST segment depressions\nin lead aVL. ST segments also depressed in leads I and V4-V6. Left atrial\nabnormality. Atrial premature beats. Acute transmural inferior wall myocardial\ninfarction is present with probable lateral extension.\n\n" }, { "category": "ECG", "chartdate": "2157-03-11 00:00:00.000", "description": "Report", "row_id": 227697, "text": "Atrial fibrillation with a moderate ventricular response. Left ventricular\nhypertrophy with secondary ST-T wave abnormalities. Compared to the previous\ntracing of anterolateral changes suggestive of myocardial injury are\nmore prominent. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2157-03-09 00:00:00.000", "description": "Report", "row_id": 227698, "text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2157-03-08 00:00:00.000", "description": "Report", "row_id": 227699, "text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of wide complex beats are no longer seen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2157-03-05 00:00:00.000", "description": "Report", "row_id": 227700, "text": "Compared to tracing #2, the rhythm is now atrial fibrillation with a rapid\nventricular response with atrial and ventricular premature beats. Other\nabnormalities persist.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2157-03-05 00:00:00.000", "description": "Report", "row_id": 227701, "text": "Compared to the previous tracing of the rate is faster and lateral\nST segment depression persist. The rhythm appears to be sinus tachycardia with\nfrequent atrial premature beats.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2157-03-04 00:00:00.000", "description": "Report", "row_id": 227702, "text": "Sinus tachycardia with atrial premature beats. Left atrial abnormality. Left\nventricular hypertrophy with secondary repolarization changes. Prior inferior\nwall myocardial infarction. Lateral ST segment depression and T wave\ninversions, which may represent ischemia versus secondary changes from left\nventricular hypertrophy. Compared to the previous tracing of ST segment\nelevation in lead V3 has now resolved. Otherwise the findings are similar.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2125-02-02 00:00:00.000", "description": "Report", "row_id": 59989, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function.\nHeight: (in) 60\nWeight (lb): 150\nBSA (m2): 1.65 m2\nBP (mm Hg): 117/61\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 09:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Hyperdynamic LVEF\n>75%. Mild resting LVOT gradient. LVOT gradient increases with Valsalva.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses and cavity\nsize are normal. Left ventricular systolic function is hyperdynamic (EF>75%).\nThere is a mild resting left ventricular outflow tract obstruction. The\ngradient increased with the Valsalva manuever. Right ventricular chamber size\nand free wall motion are normal. The ascending aorta is mildly dilated. The\naortic valve leaflets are mildly thickened. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Hyperdynamic left ventricular function with mild left ventricular\noutflow tract obstruction. No significant valvular disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002069, "text": " 1:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 yo F w/ CLL and climbing WBC, fatigue, cough, T 99, lungs clr\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cough, history of CLL.\n\n FINDINGS: A single bedside AP frontal chest radiograph obtained at 70 degrees\n is compared to . There is a new left retrocardiac opacity.\n There is persistent blunting of the left costophrenic angle. The cardiac and\n mediastinal contours are stable. The pulmonary vasculature is within normal\n limits.\n\n IMPRESSION:\n 1. New left lower lobe retrocardiac opacity. This is shown to represent\n partial left lower lobe collapse on abdominal CT. Mediastinal mass seen on CT\n not well visualized on chest radiograph.\n 2. Small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2125-02-01 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1002080, "text": " 4:14 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for diverticulitis, signs of C-diff\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 yo F w/ CLL and climbing WBC, fatigue, cough, T 99, LLQ pain, recent Azithro\n REASON FOR THIS EXAMINATION:\n eval for diverticulitis, signs of C-diff\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:04 AM\n 1. widely metastatic disease including bladder tumor, peritoneal implants, LLL\n pulmonary mass/adenopathy, mediastinal adenopathy. While metastatic bladder is\n most likely, other ddx includes metastatic ovarian given distribution of\n metastatic disease, or other unknown primary.\n 2. Marked splenomegaly with two 1 cm hypodense lesions, indeterminate but also\n suspicious\n 3. partial collapse LLL.\n ADDENDUM: nonocclusive RLL pulmonary embolism. could you call me at to\n confirm you got the addendum. thank you.\n WET READ VERSION #1 5:18 AM\n 1. widely metastatic disease including bladder tumor, peritoneal implants, LLL\n pulmonary mass/adenopathy, mediastinal adenopathy. While metastatic bladder is\n most likely, other ddx includes metastatic ovarian given distribution of\n metastatic disease, or other unknown primary.\n 2. Marked splenomegaly with two 1 cm hypodense lesions, indeterminate but also\n suspicious\n 3. partial collapse LLL.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CLL with leukocytosis, left upper quadrant pain, and\n cough. Additional history from the online medical record indicates that there\n is hematuria.\n\n TECHNIQUE: Contrast-enhanced MDCT of the abdomen and pelvis displayed in\n multiplanar collimation.\n\n COMPARISON: .\n\n CT ABDOMEN WITH CONTRAST: There is a large 5.6 x 3.2 cm mass in the inferior\n mediastinum at the G-E junction. There is a large 4.2 x 1.9 cm subcarinal mass\n that compressess the esophagus. The most superior slice also suggests an\n additional visualization of a left hilar node, which is compressing the\n superior segment bronchus of the left lower lobe resulting in postobstructive\n collapse. There is additional atelectasis at the left base with a moderate\n left-sided pleural effusion. There is a trace pericardial fluid. A\n nonocclusive pulmonary embolism is present in the visualized portions\n the right lower lobe pulmonary artery, partially visualized on this study.\n\n Widespread metastatic disease is identified, with a large, 5.9 x 3.7 cm\n heterogenous mass in the left upper quadrant, overlying the spleen, with\n a small amount of associated ascites. Innumerable additional omental,\n (Over)\n\n 4:14 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for diverticulitis, signs of C-diff\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n peritoneal, mesenteric, and retroperitoneal soft tissue\n nodules/masses consistent with metastases are also noted. There is an enlarged\n 2.7 cm mass/node in the gastrohepatic space. Multiple metastatic deposits are\n noted about and within the right adrenal gland. The spleen is markedly\n enlarged measuring 19 cm in long axis and contains multiple sub- centimeter\n hypoattenuating, indeterminate lesions. There is no free air or free fluid.\n The small bowel loops appear normal. Multiple hypodense lesions are present in\n the kidneys, all probably simple or dense cysts. No lesions are identified in\n the liver. There is no intrahepatic biliary ductal dilation. The gallbladder\n and pancreas appear normal.\n\n CT PELVIS WITH CONTRAST: There is a large lobulated mass within the right\n superior lateral wall of the bladder measuring 6.0 x 2.9 cm. There are\n multiple markedly enlarged lymph nodes along the right external iliac, right\n common iliac, and left paraaortic lymph node distributions. The rectum, colon\n and uterus appear normal. The ovaries are not identified without definite\n adenexal mass.\n\n BONE WINDOWS: No suspicious lesions are identified. Sclerosis is noted at\n the pubic symphysis.\n\n IMPRESSION:\n 1. Widely metastatic disease with innumerable peritoneal implants, including\n a large left upper quadrant mass, and bulky iliac and retroperitoneal lymph\n nodes. Lobulated mass within the bladder wall. While a primary bladder\n malignancy remains a consideration, other primary neoplasms (such as lung or\n ovarian) with implants on the bladder should also be considered.\n 2. Mediastinal adenopathy with likely left hilar adenopathy (partially\n visualized) causing post- obstructive collapse of the superior segment of the\n left upper lobe.\n 3. Nonocclusive pulmonary embolism of the right lower lobe pulmonary artery.\n 4. Massive splenomegaly with multiple indeterminate 1-cm lesions, either\n metastases or small foci of infarction secondary to splenomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2125-02-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1003297, "text": " 1:35 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for increased effusion, infiltrate\n Admitting Diagnosis: METASTATIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with metastatic ca of unknown primary.\n REASON FOR THIS EXAMINATION:\n eval for increased effusion, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP AND LATERAL CHEST :\n\n COMPARISON: .\n\n INDICATION: Metastatic cancer.\n\n Bilateral small to moderate pleural effusions are present, with slight\n improvement on the left. Cardiomediastinal contours are unchanged. Bibasilar\n areas of atelectasis adjacent to the effusions are also without change.\n\n IMPRESSION: Bilateral small to moderate pleural effusions with slight\n improvement on the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002652, "text": " 1:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: query pulmonary oedema\n Admitting Diagnosis: METASTATIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sob and bibasal crackles\n REASON FOR THIS EXAMINATION:\n query pulmonary oedema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath with bibasilar crackles.\n\n Portable AP chest dated is compared to the chest CT from and\n chest radiograph of . Patient respiratory motion degrades the image.\n The heart is normal in size; however, there is marked opacification of the\n left heart border and retrocardiac region which may represent\n atelectasis/consolidation and pleural effusion. The right lung is grossly\n clear, but there is probably a small right pleural effusion. There is no\n pneumothorax.\n\n IMPRESSION:\n 1. Patient respiratory motion degrades the quality of the image.\n 2. Left lower lobe opacification likely represents atelectasis/consolidation\n plus effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-02-02 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1002388, "text": " 3:50 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: NONCONTRAST CT, (has had recent dye load), please evaluate l\n Admitting Diagnosis: METASTATIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CLL admitted with multiple abdominal mets, and LLL\n obstruction hilar LAD on CT abdomen.\n REASON FOR THIS EXAMINATION:\n NONCONTRAST CT, (has had recent dye load), please evaluate lymphadenopathy, LLL\n collapse, infiltrate.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 85-year-old woman with chronic lymphocytic leukemia, admitted\n with abdominal metastases and left lower lobe obstruction secondary to hilar\n lymphadenopathy on the abdomen CT.\n\n Question lymphadenopathy, left lower lobe collapse and infiltrate.\n\n At the request of the referring physician, contrast was not\n administered because of a recent dye load.\n\n COMPARISONS: Limited comparison to a recent CT of the abdomen from \n which depicted the lung bases.\n\n TECHNIQUE: Axial CT images of the chest were obtained without \n contrast, and coronal and limited sagittal reformatted images, including the\n spine, were also performed.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The patient was inadvertently imaged\n during submaximal inspiration/partial expiration; there is apparently slightly\n greater than 50% narrowing of the anteroposterior dimension of the mid\n trachea, an appearance suggestive of tracheomalacia.\n\n A coarse calcification is noted the right lobe of the thyroid. There are\n calcifications along the right, the left anterior descending, and the left\n circumflex coronary arteries. The pulmonary arteries cannot be assessed for\n filling defects. There is only trace pericardial fluid but a small-to-\n moderate left- sided pleural effusion of low density is somewhat larger.\n\n Although the left anteromedial basal segment appears spared, all other\n portions of the left lower lobe are collapsed, likely due to post-obstructive\n atelectasis. The overall degree of atelectasis has progressed since the prior\n day.\n\n A large subcarinal mass of 51 x 26 mm in axial dimensions (2a:27) is now fully\n visualized, although not as well depicted without contrast. It can\n be seen to extend to the carina and also abuts the posteromedial aspects of\n each mainstem bronchus. A large mass along the right infrahilar region and\n adjacent portion of the lower left mediastinum measures 61 x 37 mm (2c:74),\n but was better depicted with contrast. The mass likely obstructs one or more\n descending basal segmental airways, but its precise origin is not fully clear.\n (Over)\n\n 3:50 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: NONCONTRAST CT, (has had recent dye load), please evaluate l\n Admitting Diagnosis: METASTATIC CANCER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There are multiple enlarged mediastinal lymph nodes. The largest is a\n paraaortic node measuring 12 mm in shortest axis dimension. There is marked\n lymphadenopathy in the left axilla. The largest node (2A:97) measures 30 x 23\n mm in axial dimensions. There are also several slightly prominent right hilar\n lymph nodes, but these are not over 8 mm in diameter.\n\n A small right-sided pleural effusion with associated atelectasis appears\n unchanged. Two calcified granulomas are noted in the right lung.\n\n Limited views of the upper abdomen again depict multiple masses, marked\n lymphadenopathy, a right adrenal mass, and marked splenomegaly. There are also\n gallstones and a new small amount of ascites. This appearance was better\n depicted on the prior CT of the abdomen.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. Subcarinal nodal mass.\n\n 2. Mass in the left infrahilar region with post- obstructive atelectasis,\n which has progressed to near left lower lobe collapse.\n\n 3. Marked left axillary lymphadenopathy, amenable to biopsy.\n\n 4. Somewhat larger bilateral pleural effusions.\n\n 5. Collapsibility of the trachea suggesting tracheomalacia.\n\n 6. Coronary artery calcifications.\n\n 7. Multiple abnormal masses in the upper abdomen, better depicted on the\n recent abdominal CT. The only new finding is trace ascites.\n\n 8. Known pulmonary embolism not visualized given the lack of contrast\n administration. The extent of pulmonary emboli, accordingly, cannot be\n assessed.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2125-02-01 00:00:00.000", "description": "INTERUP IVC", "row_id": 1002209, "text": " 4:14 PM\n IVC GRAM/FILTER Clip # \n Reason: please place IVC filter.\n Admitting Diagnosis: METASTATIC CANCER\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * INTERUP IVC 1SR ORDER BRANCH VENOUS SYSTEM *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CLL, multiple new abdominal masses, new bladder mass,\n with RLL PE, with concern for anticoagulation given hematuria.\n REASON FOR THIS EXAMINATION:\n please place IVC filter.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: IVC filter placement.\n\n INDICATION: 85-year-old woman with CLL, multiple new abdominal masses, and\n with new bladder mass. Patient has now presented with right lower lobe\n pulmonary embolism and with concern for anticoagulation given hematuria. IVC\n filter placement was requested.\n\n RADIOLOGISTS: This procedure was performed by Dr. and Dr. , the\n attending radiologist, who was present and supervising throughout the entire\n procedure.\n\n PROCEDURE AND FINDINGS: After explaining the risks and benefits of the\n procedure, an informed consent was obtained from the patient. The patient was\n placed supine on the angiographic table and the right groin was prepped and\n draped in standard sterile fashion. A preprocedure timeout was performed.\n\n After injection of local anesthesia with 1% lidocaine and using ultrasound\n guidance, access was gained into right femoral vein with a 19-gauge needle. A\n 0.035 Bentson guidewire was advanced into the IVC under fluoroscopic guidance\n and the needle was exchanged for a 5 French Omniflush catheter. Using\n Omniflush catheter and guidewire, access was gained into left common iliac\n vein and IVC venogram was obtained. IVC venogram demonstrated no thrombosis\n in left iliac, IVC, and both renal veins were noted at L2 level. Based on\n these venographic findings, it was decided to place IVC filter at L3 level.\n\n A 5 French catheter was removed and guidewire advanced into the upper IVC\n under fluoroscopic guidance. A 7 French delivery catheter was advanced over\n the wire into the IVC. A G2 IVC filter was advanced through the catheter, and\n it was deployed in the immediate infrarenal IVC at L3 level. Final abdominal\n x- ray demonstrated proper location and position of IVC filter in infrarenal\n IVC.\n\n Vascular catheter was removed and manual compression was held until hemostasis\n was achieved. The patient tolerated the procedure well and there were no\n immediate complications.\n\n (Over)\n\n 4:14 PM\n IVC GRAM/FILTER Clip # \n Reason: please place IVC filter.\n Admitting Diagnosis: METASTATIC CANCER\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Patent IVC and single renal veins at L2 level.\n Successful G2 IVC filter deployment in immediate infrarenal IVC.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2125-02-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1002091, "text": " 6:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pre-anticoag eval for cerebral masses\n Admitting Diagnosis: METASTATIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new mets to belly and chronic PE\n REASON FOR THIS EXAMINATION:\n pre-anticoag eval for cerebral masses\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with CLL and chronic PE. Please evaluate for\n pre-anticoagulation. Is there evidence of intracranial mass?\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained from the cranial vertex to\n the foramen magnum without IV contrast.\n\n FINDINGS: Periventricular hypodensity is likely secondary to chronic small\n vessel ischemic disease. There is no evidence of hemorrhage, edema, masses,\n mass effect or infarction. The ventricles and sulci are normal in caliber and\n configuration. No fracture is identified.\n\n IMPRESSION:\n\n 1. No acute intracranial abnormality.\n\n 2. Subtle involvement from metastatic disease is not well evaluated on CT\n without contrast. If clinical concern is high for metastatic involvement of\n the brain, MRI imaging with gadolinium administration would be the preferable\n technique.\n\n" }, { "category": "ECG", "chartdate": "2125-02-01 00:00:00.000", "description": "Report", "row_id": 106991, "text": "Baseline artifact. Sinus rhythm with borderline resting sinus tachycardia.\nLeft axis deviation consistent with left anterior fascicular block. Delayed\nprecordial transition. Non-specific ST-T wave changes. Compared to the\nprevious tracing of heart rate is faster. Voltage is somewhat lower.\nBorderline QTc interval prolongation is again noted.\n\n" }, { "category": "Physician ", "chartdate": "2125-02-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318158, "text": "Chief Complaint:abdominal pain, hematuria, transient hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo F w/ CLL presents with hematuria, abd pain and transient\n hypotension in ED, found to have extensive masses throughout abd and\n pelvis/bladder concerning for widely metastatic disease of unclear\n primary , also with evidence of partial LLL collapse and PE\n 24 Hour Events:\n received 1 units PRBC with appropriate bump\n IVC filter placed yesterday\n abd pain controlled with low dose morphine IV\n History obtained from Patient, house staff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37\nC (98.6\n HR: 91 (78 - 97) bpm\n BP: 117/61(75) {95/50(61) - 119/65(75)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 415 mL\n 122 mL\n PO:\n 120 mL\n TF:\n IVF:\n 40 mL\n 2 mL\n Blood products:\n 375 mL\n Total out:\n 730 mL\n 340 mL\n Urine:\n 730 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -218 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), P2, no RV strain\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: b/b), no\n wheeze appreciated\n Abdominal: Soft, Distended, Tender: to palpation, no R/G, + BS\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 222 K/uL\n 97 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 113 mEq/L\n 144 mEq/L\n 29.0 %\n 24.1 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n WBC\n 26.3\n 21.6\n 24.1\n Hct\n 25.9\n 24.9\n 29.0\n Plt\n \n Cr\n 0.6\n 0.6\n Glucose\n 105\n 97\n Other labs: PT / PTT / INR:13.8/25.5/1.2, ALT / AST:17/46, Alk Phos / T\n Bili:66/1.7, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.2 g/dL, Ca++:8.2\n mg/dL, Mg++:1.8 mg/dL, PO4:3.3 mg/dL\n Imaging: chest ct ordered\n Assessment and Plan\n 85 yo F w/ CLL presents with hematuria, abd pain and transient\n hypotension in ED, found to have extensive masses throughout abd and\n pelvis/bladder concerning for widely metastatic disease of unclear\n primary , also with evidence of partial LLL collapse and PE\n Main issues remain:\n # Hypoxia\nremains stable on 2L NC\n # PE--stable from hemodynamic and respiratory standpoint and\n feel is high risk for anticoagulation given extensive bladder mass and\n hematuria w/ recent h/h drop\n Had IVC filter placed yesterday and remains on dvt prophy with\n sc heparin\n Echo to assess RV fx\n #? post-obstructive pna--f/u ct chest (noncontrast) to further\n asses lung involvement and evaluate LLL, though without contrast\n evaluation of mediastinal LN is limited, also most likely from CLL, may\n identify bx-able lesion, though again if concern for transformation of\n CLL fna less helpful at making dx\n continue empiric antbx with levo flagyl, broadening coverage if\n worsening respiratory or clinical status\n # Cough\nadd tessalon perles, robitussion, flovent and consider\n codeine\n #CLL/malignancy\nnow with widely metastatic cancer, primary site\n unclear\nsome findings likely secondary to known CLL, with possibility\n of transformation (Richters) though bladder mass seems less c/w this\n picture --? Bladder, breast, renal cell ca,\n Continue toward obtaining dx--tissue/cytologic--urology c/s and\n onc input, appreciated, urine for cytology, given high risk for\n resection for uncontrolled bleeding.\n Chest ct to further eval for lung involvement as above\n # anemia--hct below baseline and will follow, now post 1-unit\n prbc's w/ appropriate bump,\n hemolysis contributing\nstarting folate and holding on\n prednisone pending tissue dx as this could interfere\n # uric acid elevation--etiology unclear but question of tumor\n lysis, renal fx remains stable and other lytes stable, continue\n hydration and follow tumor lysis labs\n # LFT s\ntrend\n # Transient hypotension\nnow resolved\n most likely secondary to combination of medication effect from\n morphine and hypovolemia , less likely d/t PE and/or sepsis/infection\n remains stable hemodynamically\n h/h with expected bump post transfusion, continuing to monitor\n f/u cx\ns and continue empiric antibx with levo flagyl\n # leukocytosis--difficult to interpret in setting of CLL--reactive\n verses infection-trending down and now near prior baseline\n onc c/s, following, infection w/u as noted, c diff\n #abd pain--multiple masses throughout abdomen likely etiology, continue\n empiric antibx and pain control with morphine\n #hematuria--TWF--good urine outpt without clot not requiring urine\n irrigation\n h/h monitoring and transfusion as above, Q 3 hr urine cytology\n ordered\n # HTN\nresume home regimen\n # Asthma--home meds\n Remainder per resident note, agree with plan as documented\n ICU Care\n Nutrition:\n Comments: advance for diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor if h/h remain stable on next lab check\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2125-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318086, "text": "This is an 85yo female with PMH CLL, not previously requiring\n treatment, who presented to EW with persistent abd. Pain and hematuria\n starting . CT of abd/pelvis showed multiple new metastasis and new\n mass in bladder. Also RLL PE. Pt. transferred here to MSICU for\n further work-up. Brought to IR last evening for placement of IVC filter\n as anticoagulation not an option at this time d/t bleeding tumor in\n bladder. Pt. hemodynamically stable. Is c/o some abd. Pain but eases\n with prn morphine. No blood noted in urine this shift.\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Multiple new omental, peritoneal, mesenteric and retroperitoneal masses\n found on CT. Also new mass found in bladder found to be source of\n hematuria. Pt. c/o abd. Pain. Abdomen distended and tender.\n Action:\n Pt. medicated with morphine 1mg x1 with some effect. Pt. prefers to\n take Tylenol. Also repositioned with good effect. Pt. given 1 unit of\n blood for a hct of 25. Oncology spoke with family reguarding CT\n results. Pt. made DNR/DNI\n Response:\n Pt. appears comfortable at this time. Repeat Hct pending.\n Plan:\n Pt. to go for CT of abd, pelvis today. Probable biopsy to be done of\n tumor in bladder and maybe tumor in abdomen to r/o malignancy. Serial\n Hcts. Monitor hemodynamic status closely. Medicate for abd. As needed.\n Hypotension (not Shock)\n Assessment:\n Yesterday pt. hypotensive as low as 70\ns systolic. This shift sbp low\n 90\ns to low 100\ns. Unable to determine if this was d/t hypovolemia,\n sepsis or the 6mg morphine given to pt. in EW.\n Action:\n Blood and urine cultures sent yesterday. Started on po levaquin and\n flagyl. Pt. given a unit of blood as well for hct of 25..\n Response:\n Am labs pending. Culture results pending. No hypotension this shift.\n Plan:\n Continue to monitor serial Hcts. Replete with blood products as needed.\n Monitor hemodynamic status closely.\n" }, { "category": "Nutrition", "chartdate": "2125-02-02 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 318138, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 85 YO female w/ hx of B-cell CLL mets to omental, peritoneal,\n mesenteric, retroperitoneal but of unknown primary. Consulted for poor\n po intake. Diet just advanced to Regular/Diabetic. Recommend liberalize\n diet to Regular given age, <intake & BG in good control. Patient w/\n abdominal pain likely d/t mets dz. Will provide Ensure supplements TID.\n If aggressive care is indicated, patient will likely need enteral feeds\n (PPFT vs J-tube if for long-term) if unable to tolerate adequate po\"s\n or unable to take supplements. Please consult nutrition if nutrition\n support is desired. Will follow plan.\n" }, { "category": "Physician ", "chartdate": "2125-02-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318140, "text": "Chief Complaint: Hematuria, cough, abdominal pain\n 24 Hour Events:\n - transfused 1 unit pRBCs\n - IVC filter placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37\nC (98.6\n HR: 86 (78 - 97) bpm\n BP: 108/50(66) {95/50(61) - 119/65(73)} mmHg\n RR: 16 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 415 mL\n 2 mL\n PO:\n TF:\n IVF:\n 40 mL\n 2 mL\n Blood products:\n 375 mL\n Total out:\n 730 mL\n 300 mL\n Urine:\n 730 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale, No(t) Sclera edema, non-reactive,\n surgical pupils\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: L base)\n Abdominal: Bowel sounds present, Distended, Tender:\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 222 K/uL\n 9.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 113 mEq/L\n 144 mEq/L\n 29.0 %\n 24.1 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n WBC\n 26.3\n 21.6\n 24.1\n Hct\n 25.9\n 24.9\n 29.0\n Plt\n \n Cr\n 0.6\n 0.6\n Glucose\n 105\n 97\n Other labs: PT / PTT / INR:13.8/25.5/1.2, ALT / AST:17/46, Alk Phos / T\n Bili:66/1.7, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.2 g/dL, Ca++:8.2\n mg/dL, Mg++:1.8 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused. S/P 1 unit pRBCs\n with appropriate bump\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - f/u 12pm HCT, consider re-checking if down\n - transfuse for HCT<26\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - chest CT to better characterize lung pathology\n - continue levo/flagyl, broaden if looks ill.\n - s/p IVC filter placement in setting of PE\n .\n # cough\n post obstructive PNA v mechanical irritation from bulky LAD\n - guaifenisen\n - consider adding phenergan for spasm quality of cough\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, likely hemolysis, no liver lesions on CT.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - low dose morphine and tylenol for abd pain, though would be cautious\n with morphine given BP drop in ED.\n - hyperbilirubinemia likely be hemolysis, no biliary dilation on\n CT, no RUQ pain.\n - re-fractionate bilirubin.\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - 3 way foley.\n - appreciate urology consult re biopsy of bladder mass\n unresectable,\n will follow q3h urine cytology looking for evidence of CLL v TCC\n - hold aspirin.\n - check 12 pm HCT\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, likely\n smoldering hemolysis in setting of large tumor burden\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , now positive, hemolysis in setting\n of large tumor burden.\n - heme/onc consult appreciate.\n - will obtain q3h urine samples for cytology, in effort to obtain a dx\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - restart diet, replete lytes prn\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: Transfer to floor if HCT stable\n" }, { "category": "Physician ", "chartdate": "2125-02-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318143, "text": "Chief Complaint: Hematuria, cough, abdominal pain\n 24 Hour Events:\n - transfused 1 unit pRBCs\n - IVC filter placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37\nC (98.6\n HR: 86 (78 - 97) bpm\n BP: 108/50(66) {95/50(61) - 119/65(73)} mmHg\n RR: 16 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 415 mL\n 2 mL\n PO:\n TF:\n IVF:\n 40 mL\n 2 mL\n Blood products:\n 375 mL\n Total out:\n 730 mL\n 300 mL\n Urine:\n 730 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale, No(t) Sclera edema, non-reactive,\n surgical pupils\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: L base)\n Abdominal: Bowel sounds present, Distended, Tender:\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 222 K/uL\n 9.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 113 mEq/L\n 144 mEq/L\n 29.0 %\n 24.1 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n WBC\n 26.3\n 21.6\n 24.1\n Hct\n 25.9\n 24.9\n 29.0\n Plt\n \n Cr\n 0.6\n 0.6\n Glucose\n 105\n 97\n Other labs: PT / PTT / INR:13.8/25.5/1.2, ALT / AST:17/46, Alk Phos / T\n Bili:66/1.7, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.2 g/dL, Ca++:8.2\n mg/dL, Mg++:1.8 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused. S/P 1 unit pRBCs\n with appropriate bump\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - f/u 12pm HCT, consider re-checking if down\n - transfuse for HCT<26\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - chest CT to better characterize lung pathology\n - continue levo/flagyl, broaden if looks ill.\n - s/p IVC filter placement in setting of PE\n .\n # cough\n post obstructive PNA v mechanical irritation from bulky LAD\n - guaifenisen\n - consider adding phenergan for spasm quality of cough\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, likely hemolysis, no liver lesions on CT.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - low dose morphine and tylenol for abd pain, though would be cautious\n with morphine given BP drop in ED.\n - hyperbilirubinemia likely be hemolysis, no biliary dilation on\n CT, no RUQ pain.\n - re-fractionate bilirubin.\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - 3 way foley.\n - appreciate urology consult re biopsy of bladder mass\n unresectable,\n will follow q3h urine cytology looking for evidence of CLL v TCC\n - hold aspirin.\n - check 12 pm HCT\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, likely\n smoldering hemolysis in setting of large tumor burden\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , now positive, hemolysis in setting\n of large tumor burden.\n - heme/onc consult appreciate.\n - will obtain q3h urine samples for cytology, in effort to obtain a dx\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - restart diet, replete lytes prn\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: Transfer to floor if HCT stable\n ------ Protected Section ------\n A&P\n # PE - IVC filter placed , systemic anticoagulation deferred in\n setting of hematuria\n ------ Protected Section Addendum Entered By: , MD\n on: 11:52 ------\n" }, { "category": "Nursing", "chartdate": "2125-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318076, "text": "Pt is an 85 yo Russian speaking F, formerly a pharmacist, who presented\n to increased lethargy and clots in urine as per her son. Was\n experiencing abdominal pain\n" }, { "category": "Physician ", "chartdate": "2125-02-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 318078, "text": "Chief Complaint: abd pain and hematuria , transient hypotension in\n ED\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo F with stable CLL, not requiring treatment, presents to ED with\n abd pain, hematuria.\n C/o several month h/o ns, fatigue, poor appetite and intermittent L abd\n discomfort Also notes tinnitus, ongoing new since .\n Was seen by pcp for viral uri sx/dry cough\n Returned to PCP w/ ongoing sputum production and also had noted to\n have episode of hematuria and ongoing L LQ pelvic/abd pain. Treated\n with azithro for presumed CAP/bronchitis. Labs showed increase in WBC\n to 40 from baseline 's and blood in urine. Abd u/s performed as\n outpt showed splenomegaly with new echogenic splenic lesions.\n Yesterday developed recurrent hematuria with clots and sensation of\n incomplete voiding, no cva pain or suprapubic pain, prompting ED\n visit. Pt\ns cough persists though unchanged X past week and abd pain\n intermittent and at baseline.\n Denies CP, SOB, syncope, no emesis or nausea\n In ED had neg head ct for mets or bleed, cxr and ct abd and pelvis\n performed identifying multiple masses at bladder, RLL pe, and \n collapse with hilar LAD\n Emperic levo and flagyl started for possible post-obstructive pna\n verses GI infection. Transient hypotension to 70/30 following 6 mg of\n IV morphine with response to 2 L IVF.\n Transferred to for further care\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records,\n housestaff\n Allergies:\n No Known Drug Allergies\n HOME medications:\n ALBUTEROL 17 GM--Take 2 puff twice a day as needed\n AMBIEN 10MG--One by mouth at bedtime as needed\n ASPIRIN 81 MG--One by mouth every day\n ATENOLOL 25 mg--1. tablet(s) by mouth once a day - NOT TAKING.\n Atorvastatin 10 mg--0.5 tablet(s) by mouth once a day\n CLONAZEPAM 0.5 mg--one tablet(s) every evening as needed\n COSOPT 0.5 %-2 %--1 gtt os twice a day to LEFT EYE\n COZAAR 50 mg--1 tablet(s) by mouth once a day\n Citalopram 20 mg--0.5 tablet(s) by mouth at bedtime\n Flovent HFA 110 mcg/Actuation--take 2 puffs twice a day\n HYDROCHLOROTHIAZIDE 12.5MG--Take one by mouth daily\n LORATADINE 10 mg--1 tablet(s) by mouth once a day as needed for\n congestion, ear discomfort (itching)\n NITROGLYCERIN 0.3 mg--11 tablet(s) sublingually for chest pain;\n repeat x 1 after 5 minutes - HAS NEVER USED.\n RANITIDINE HCL 150 mg--1 tablet(s) by mouth daily\n Past medical history:\n Family history:\n Social History:\n - CLL - referred to heme/onc (( ), for anemia, leukocytosis,\n found on flow cytometry confirmed B-cell chronic lymphocytic\n leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia,\n splenomegaly), so no plan for treatment as of .\n - htn\n - asthma\n - hyperlipidemia\n - OA - left hip, knee, previously on vioxx.\n - tah/bso fibroids\n - glucose intolerance (not on meds, a1c 6.1->5.5)\n - glaucoma\n - cancer screening: colonoscopy on showed 2 adenomatous\n polyps, one in the transverse colon and the other in the\n descending colon. Annual mammographies have been negative last in \n NC\n Occupation: lived near , primary caregiver husband\n Drugs: none\n Tobacco:\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss, night sweats\n Eyes: tinnitus\n Ear, Nose, Throat: No(t) Dry mouth, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: Joint pain, No(t) Myalgias, chronic knee\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Daytime\n somnolence\n Signs or concerns for abuse : No\n Pain: Minimal\n Flowsheet Data as of 04:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 91 (91 - 97) bpm\n BP: 106/56(68) {99/56(68) - 116/58(71)} mmHg\n RR: 24 (23 - 26) insp/min\n SpO2: 97% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 430 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -430 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, R axillary LAD\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender: R\n LQ, Obese, impressive splenomegally\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: all 4 ext\n Sedated, No(t) Paralyzed, Tone: normal\n Labs / Radiology\n 229 K/uL\n 25.9 %\n 8.7 g/dL\n 26.3 K/uL\n 12:53 PM\n WBC\n 26.3\n Hct\n 25.9\n Plt\n 229\n Other labs: ALT / AST:15/44, Alk Phos / T Bili:68/1.2\n Microbiology: blood and urine cx's sent\n ECG: lad nsr at 91, no acute changes and unchanged from prior\n CXR : Left lower lobe opacity, later shown to represent partial\n left lower lobe collapse on subsequent abdominal CT. The mediastinal\n adenopathy is not well appreciated on the chest radiograph.\n 2. Persistent left pleural effusion.\n CT abd and pelvis :\n 1. widely metastatic disease including bladder tumor, peritoneal\n implants, pulmonary mass/adenopathy, mediastinal adenopathy. While\n metastatic bladder is most likely, other ddx includes metastatic\n ovarian given distribution of metastatic disease, or other unknown\n primary.\n 2. Marked splenomegaly with two 1 cm hypodense lesions, indeterminate\n but also suspicious\n 3. partial collapse .\n 4. nonocclusive RLL pulmonary embolism.\n Assessment and Plan\n 85 yo F w/ CLL presents with hematuria and abd pain and transient\n hypotension in ED, found to have extensive masses throughout abd and\n pelvis/bladder concerning for widely metastatic disease of unclear\n primary and partially collapse and PE\n # Transient hypotension\nrelated to medication effect form morphine\n verses blood loss, PE, and less likely sepsis/infection from urine,\n post-obstructive pna,\n HD stable after 2 L IVF\n Infection w/u underway continuing empiric antibx with levo flagyl\n Serial h/h\ntransfusing for further Hct drop, keep activetype and\n cross and follow Q 8 hour cbc\n Large bore piv access\n # PE--stable from hemodynamic and respiratory standpoint and feel is\n high risk for anticoaglation given extensive masses hematuria and h/h\n drop\n IR for IVC filter placement\n #CLL/malignancy--primary site unclear--? Bladder, breast, renal cell\n ca, less likely CLL with progression, has had normal mammograms and\n polyps on recent colonoscopy\n pursue tissue diagnosis--urology c/s and onc input\n # uric acid elevation--etiology unclear but question of tumor\n lysis, renal fx stable and other lytes stable, continue hydration,\n follow tumor lysis labs\n # LFT abnormalities with elevated t bili-check hemolyisis labs,\n trend LFTs, DAT, check smear\n #? post-obstructive pna--f/u ct chest to further asses lung\n involvement, stable on 2 L NC\n continue empiric antbx with levo flagyl, broadening coverage if\n worsening respiratory or clinical status\n # leukocytosis--difficult to interpret in setting of CLL--reactive\n verses infection-trending down though significantly increased from\n baseline, onc c/s, follow and check differential, infection w/u as\n noted, c diff\n #abd pain--multiple masses throughout abdomen likely etiology, continue\n empiric antibx and pain control\n #hematuria--TWF--clear urine, irrigate if clots, h/h monitoring and\n transfusion as above\n # HTN--holding home meds given hypotension in ed\n Remainder per resident note, agree with plan as documented\n ICU Care\n Nutrition:\n Comments: NPO for IV filter placement\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR/DNI (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 19:55 ------\n" }, { "category": "General", "chartdate": "2125-02-01 00:00:00.000", "description": "Generic Note", "row_id": 318080, "text": "Attending MICU Note\n Chief Complaint: abd pain and hematuria , transient hypotension in\n ED\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo F with stable CLL, not requiring treatment, presents to ED with\n abd pain, hematuria.\n C/o several month h/o ns, fatigue, poor appetite and intermittent L abd\n discomfort Also notes tinnitus, ongoing new since .\n Was seen by pcp for viral uri sx/dry cough\n Returned to PCP w/ ongoing sputum production and also had noted to\n have episode of hematuria and ongoing L LQ pelvic/abd pain. Treated\n with azithro for presumed CAP/bronchitis. Labs showed increase in WBC\n to 40 from baseline 's and blood in urine. Abd u/s performed as\n outpt showed splenomegaly with new echogenic splenic lesions.\n Yesterday developed recurrent hematuria with clots and sensation of\n incomplete voiding, no cva pain or suprapubic pain, prompting ED\n visit. Pt\ns cough persists though unchanged X past week and abd pain\n intermittent and at baseline.\n Denies CP, SOB, syncope, no emesis or nausea\n In ED had neg head ct for mets or bleed, cxr and ct abd and pelvis\n performed identifying multiple masses at bladder, RLL pe, and \n collapse with hilar LAD\n Emperic levo and flagyl started for possible post-obstructive pna\n verses GI infection. Transient hypotension to 70/30 following 6 mg of\n IV morphine with response to 2 L IVF.\n Transferred to for further care\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records,\n housestaff\n Allergies:\n No Known Drug Allergies\n HOME medications:\n ALBUTEROL 17 GM--Take 2 puff twice a day as needed\n AMBIEN 10MG--One by mouth at bedtime as needed\n ASPIRIN 81 MG--One by mouth every day\n ATENOLOL 25 mg--1. tablet(s) by mouth once a day - NOT TAKING.\n Atorvastatin 10 mg--0.5 tablet(s) by mouth once a day\n CLONAZEPAM 0.5 mg--one tablet(s) every evening as needed\n COSOPT 0.5 %-2 %--1 gtt os twice a day to LEFT EYE\n COZAAR 50 mg--1 tablet(s) by mouth once a day\n Citalopram 20 mg--0.5 tablet(s) by mouth at bedtime\n Flovent HFA 110 mcg/Actuation--take 2 puffs twice a day\n HYDROCHLOROTHIAZIDE 12.5MG--Take one by mouth daily\n LORATADINE 10 mg--1 tablet(s) by mouth once a day as needed for\n congestion, ear discomfort (itching)\n NITROGLYCERIN 0.3 mg--11 tablet(s) sublingually for chest pain;\n repeat x 1 after 5 minutes - HAS NEVER USED.\n RANITIDINE HCL 150 mg--1 tablet(s) by mouth daily\n Past medical history:\n Family history:\n Social History:\n - CLL - referred to heme/onc (( ), for anemia, leukocytosis,\n found on flow cytometry confirmed B-cell chronic lymphocytic\n leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia,\n splenomegaly), so no plan for treatment as of .\n - htn\n - asthma\n - hyperlipidemia\n - OA - left hip, knee, previously on vioxx.\n - tah/bso fibroids\n - glucose intolerance (not on meds, a1c 6.1->5.5)\n - glaucoma\n - cancer screening: colonoscopy on showed 2 adenomatous\n polyps, one in the transverse colon and the other in the\n descending colon. Annual mammographies have been negative last in \n NC\n Occupation: lived near , primary caregiver husband\n Drugs: none\n Tobacco:\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss, night sweats\n Eyes: tinnitus\n Ear, Nose, Throat: No(t) Dry mouth, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: Joint pain, No(t) Myalgias, chronic knee\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Daytime\n somnolence\n Signs or concerns for abuse : No\n Pain: Minimal\n Flowsheet Data as of 04:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 91 (91 - 97) bpm\n BP: 106/56(68) {99/56(68) - 116/58(71)} mmHg\n RR: 24 (23 - 26) insp/min\n SpO2: 97% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 430 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -430 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, R axillary LAD\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender: R\n LQ, Obese, impressive splenomegally\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: all 4 ext\n Sedated, No(t) Paralyzed, Tone: normal\n Labs / Radiology\n 229 K/uL\n 25.9 %\n 8.7 g/dL\n 26.3 K/uL\n 12:53 PM\n WBC\n 26.3\n Hct\n 25.9\n Plt\n 229\n Other labs: ALT / AST:15/44, Alk Phos / T Bili:68/1.2\n Microbiology: blood and urine cx's sent\n ECG: lad nsr at 91, no acute changes and unchanged from prior\n CXR : Left lower lobe opacity, later shown to represent partial\n left lower lobe collapse on subsequent abdominal CT. The mediastinal\n adenopathy is not well appreciated on the chest radiograph.\n 2. Persistent left pleural effusion.\n CT abd and pelvis :\n 1. widely metastatic disease including bladder tumor, peritoneal\n implants, pulmonary mass/adenopathy, mediastinal adenopathy. While\n metastatic bladder is most likely, other ddx includes metastatic\n ovarian given distribution of metastatic disease, or other unknown\n primary.\n 2. Marked splenomegaly with two 1 cm hypodense lesions, indeterminate\n but also suspicious\n 3. partial collapse .\n 4. nonocclusive RLL pulmonary embolism.\n Assessment and Plan\n 85 yo F w/ CLL presents with hematuria and abd pain and transient\n hypotension in ED, found to have extensive masses throughout abd and\n pelvis/bladder concerning for widely metastatic disease of unclear\n primary and partially collapse and PE\n # Transient hypotension\nrelated to medication effect form morphine\n verses blood loss, PE, and less likely sepsis/infection from urine,\n post-obstructive pna,\n HD stable after 2 L IVF\n Infection w/u underway continuing empiric antibx with levo flagyl\n Serial h/h\ntransfusing for further Hct drop, keep activetype and\n cross and follow Q 8 hour cbc\n Large bore piv access\n # PE--stable from hemodynamic and respiratory standpoint and feel is\n high risk for anticoaglation given extensive masses hematuria and h/h\n drop\n IR for IVC filter placement, would check echo to assess RV fx\n #CLL/malignancy\nnow with widely metastatic cancer with primary site\n unclear--? Bladder, breast, renal cell ca, less likely CLL with\n progression, has had normal mammograms and polyps on recent colonoscopy\n pursue tissue diagnosis--urology c/s and onc input, urine for\n cytology, feel that bladder mass is large and of high risk for\n resection, will obtain chest ct to further eval for lung involvement\n and talk with radiology regarding possible ct-guided FNA\n # uric acid elevation--etiology unclear but question of tumor\n lysis, renal fx stable and other lytes stable, continue hydration,\n follow tumor lysis labs\n # LFT abnormalities with elevated t bili-check hemolyisis labs,\n trend LFTs, DAT, check smear\n #? post-obstructive pna--f/u ct chest to further asses lung\n involvement, stable on 2 L NC\n continue empiric antbx with levo flagyl, broadening coverage if\n worsening respiratory or clinical status\n # leukocytosis--difficult to interpret in setting of CLL--reactive\n verses infection-trending down though significantly increased from\n baseline, onc c/s, follow and check differential, infection w/u as\n noted, c diff\n #abd pain--multiple masses throughout abdomen likely etiology, continue\n empiric antibx and pain control\n #hematuria--TWF--clear urine, irrigate if clots, h/h monitoring and\n transfusion as above\n # HTN--holding home meds given hypotension in ed\n Remainder per resident note, agree with plan as documented\n ICU Care\n Nutrition:\n Comments: NPO for IV filter placement\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR/DNI (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 19:55 ------\n" }, { "category": "Nursing", "chartdate": "2125-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318147, "text": "85yo female with PMH CLL, not previously requiring treatment, who\n presented to EW with persistent abd. pain & hematuria starting .\n CT of abd/pelvis showed multiple new metastasis and new mass in\n bladder. Also RLL PE.\n Pt. transferred here to MSICU for further work-up. IVC filter placed\n as anticoagulation not an option at this time d/t bleeding tumor\n in bladder.\n Pt. hemodynamically stable. c/o some abd. pain but eases with prn\n morphine. No blood noted in urine since ICU admission.\n" }, { "category": "Nursing", "chartdate": "2125-02-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 318148, "text": "85yo female with PMH CLL, not previously requiring treatment, who\n presented to EW with persistent abd. pain & hematuria starting\n . Other PMH sig for anemia, HTN, hyperlipidemia, asthma, glucose\n intolerance, L knee osteoarthritis.\n NKDA\n CT of abd/pelvis showed multiple new metastasis and new mass in\n bladder. Also RLL PE. Pt. transferred to MSICU for further work-up.\n IVC filter placed as anticoagulation not an option at this time\n d/t bleeding tumor in bladder.\n Pt. hemodynamically stable. c/o some abd. Pain but eases with prn\n morphine. No blood noted in urine since ICU admit.\n After discussion with pt & family pt DNR/DNI.\n" }, { "category": "Physician ", "chartdate": "2125-02-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 318066, "text": "Chief Complaint: hematuria, cough, abdominal pain\n HPI:\n 85 F h/o stage 0 CLL, not requring tx previously, presents to ED for\n persistent cough/abdominal pain, and hematuria.\n .\n Pt notes ~2 mo increasing fatigue, nightsweats, n, decreased appetite,\n and increasing left side abdominal pain (intermittent, no relation to\n food, BM, sharp, no diarrhea, constipation, melena). She was seen by\n PCP , felt to have viral URI, symptoms persisted, and seen again\n with persistent cough (intermittently productive,\n yellow-white), single episode of hematuria (clear red, not clot), and\n LLQ abdominal pain, treated with azithromycin, and abdominal USN\n obtained which revealed new splenomegaly with new 1.5-cm echogenic\n area.\n .\n On , pt noted recurrent episode of \"strong blood in urine.\"\n Describes clear red +clots, +feeling incomplete voiding, no suprapubic\n pain, no CVA tenderness. Also notes R LE pain.\n .\n Pt presented to the ED with VS: 98.1 79 113/69 16 100%RA. In the\n ED, CXR with LUL collapse, CT ABD/PELVIS with multiple new metastasis,\n and new mass in bladder. also RLL PE. UA +hematuria, + UTI. pt given\n levo, flagyl, morphine 2mg x3 for pain. BP then noted to drop to\n 70/37, pt received total 2L IVF, although timing unclear, with BP\n improved to 102/55s (?dehyration vs sepsis vs morphine). No central\n line placed. CT head obtained in anticipation of possible\n anticoagulation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - CLL - referred to heme/onc (( ), for anemia, leukocytosis,\n found on flow cytometry confirmed B-cell chronic lymphocytic\n leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia,\n splenomegaly), so no plan for treatment as of .\n - htn\n - asthma\n - hyperlipidemia\n - OA - left hip, knee, previously on vioxx.\n - tah/bso fibroids.\n - glucose intolerance (not on meds, a1c 6.1->5.5)\n - glaucoma\n - cancer screening: colonoscopy on showed 2 adenomatous\n polyps, one in the transverse colon and the other in the\n descending colon. Annual mammographies have been negative.\n she lives with her husband. They have 2 children, 1 son and 1\n daughter, in their 50s and 60s, respectively.\n - worked as a pharmacist in , . She was 80 miles from the\n Chernobyl accident in , leaving on the 3rd day of the radiation\n exposure, although she's not certain if she was in fact exposed to\n radiation. 3 months later, she returned to her residence. Some of her\n co-workers had thyroid concerns after the Chernobyl\n accident. She moved to the U.S. in .\n .\n No family history of hematologic or oncologic dyscrasias. Both parents\n died of strokes. A sister, her only\n sibling, had \"pancreatic\" obstruction, not cancer related, and died at\n age 64. The patient's daughter had breast cancer at age 54.\n Occupation: retired\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: lives with huband, indepdent of adls, worked as pharmacist in\n , 80mi from chernobyl accident in , left area on 3rd day of\n radiation exposure, returned 3 mo later.\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: tinnitus\n Respiratory: Cough, Dyspnea\n Gastrointestinal: Abdominal pain, Nausea\n Heme / Lymph: Lymphadenopathy\n Flowsheet Data as of 03:03 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 91 (91 - 97) bpm\n BP: 106/56(68) {99/56(68) - 116/58(71)} mmHg\n RR: 24 (23 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 430 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -430 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical adenopathy, axillary adenopathy (R), left inguinal\n adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LLL)\n Abdominal: Soft, Bowel sounds present, Distended, +splenomegaly\n ~5inches below cv angle\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): person, place, t\n ime., Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 229 K/uL\n 8.7 g/dL\n 25.9 %\n 26.3 K/uL\n [image002.jpg]\n \n 2:33 A2/28/ 12:53 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 26.3\n Hct\n 25.9\n Plt\n 229\n Other labs: ALT / AST:15/44, Alk Phos / T Bili:68/1.2\n Assessment and Plan\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused.\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - serial HCT for today, q8h.\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n - LENIs to consider IVC filter, consider CTA, as would be useful to\n better characterize thoracic lymphadenopathy in terms best site for\n biopsy.\n - ?heparin, consider hold off on anticoag for now given stable\n respiratory status, and ?hemodynamically significant bleeding.\n .\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - CTA to characterize PE, also to characterize thoracic lymphadenoapthy\n and metastasis with regard to potential biopsy sites, will switch to\n high res CT chest tommorow as will place IVC filter empirically given\n that hct is dropping and prefer to avoid anticoagulation for tonight.\n - continue levo/flagyl, broaden if looks ill.\n - consider heparin gtt after CTA, hematuria stable presently\n - check sputum cx.\n .\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, could be hemolysis, no liver lesions on CT.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - tylenol, ultram prn for abd pain, would use 0.5-1mg morphine for abd\n pain if needed, though would be cautious given BP drop in ED.\n - hyperbilirubinemia may be hemolysis, no biliary dilation on CT,\n no RUQ pain.\n - fractionate bilirubin.\n .\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - place 3 way foley.\n - continuous bladder irrigation.\n - urology consult re biopsy of bladder mass.\n - hold aspirin.\n - cycle hct q8hr today.\n .\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, ddx also\n includes hemolysis.\n - trend LFTs.\n - fractionate bili, check smear, haptoglobin, DAT.\n .\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , could represent hemolysis.\n - heme/onc consult.\n - fractionate bilirubin, check haptoglobin, LDH, platelets smear, DAT\n - d/w team best site for tissue biopsy.\n - elevated uric acid, ?tumor lysis-> will continue gentle IVF\n hydration, follow uric acid, phos, ca.\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - npo for now, though biopsy unlikely, then diabetic diet.\n .\n #PPx\n - pneumoboots after LENIs, ppi.\n - bowel regimen prn.\n .\n #CODE: DNR/DNI, d/w pt and her son.\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: IVC filter\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-02-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 318071, "text": "Chief Complaint: abd pain and hematuria , transient hypotension in\n ED\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo F with stable CLL, not requiring treatment, presents to ED with\n abd pain, hematuria.\n C/o several month h/o ns, fatigue, poor appetite and intermittent L abd\n discomfort Also notes tinnitus, ongoing new since .\n Was seen by pcp for viral uri sx/dry cough\n Returned to PCP w/ ongoing sputum production and also had noted to\n have episode of hematuria and ongoing L LQ pelvic/abd pain. Treated\n with azithro for presumed CAP/bronchitis. Labs showed increase in WBC\n to 40 from baseline 's and blood in urine. Abd u/s performed as\n outpt showed splenomegaly with new echogenic splenic lesions.\n Yesterday developed recurrent hematuria with clots and sensation of\n incomplete voiding, no cva pain or suprapubic pain, prompting ED\n visit. Pt\ns cough persists though unchanged X past week and abd pain\n intermittent and at baseline.\n Denies CP, SOB, syncope, no emesis or nausea\n In ED had neg head ct for mets or bleed, cxr and ct abd and pelvis\n performed identifying multiple masses at bladder, RLL pe, and \n collapse with hilar LAD\n Emperic levo and flagyl started for possible post-obstructive pna\n verses GI infection. Transient hypotension to 70/30 following 6 mg of\n IV morphine with response to 2 L IVF.\n Transferred to for further care\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records,\n housestaff\n Allergies:\n No Known Drug Allergies\n HOME medications:\n ALBUTEROL 17 GM--Take 2 puff twice a day as needed\n AMBIEN 10MG--One by mouth at bedtime as needed\n ASPIRIN 81 MG--One by mouth every day\n ATENOLOL 25 mg--1. tablet(s) by mouth once a day - NOT TAKING.\n Atorvastatin 10 mg--0.5 tablet(s) by mouth once a day\n CLONAZEPAM 0.5 mg--one tablet(s) every evening as needed\n COSOPT 0.5 %-2 %--1 gtt os twice a day to LEFT EYE\n COZAAR 50 mg--1 tablet(s) by mouth once a day\n Citalopram 20 mg--0.5 tablet(s) by mouth at bedtime\n Flovent HFA 110 mcg/Actuation--take 2 puffs twice a day\n HYDROCHLOROTHIAZIDE 12.5MG--Take one by mouth daily\n LORATADINE 10 mg--1 tablet(s) by mouth once a day as needed for\n congestion, ear discomfort (itching)\n NITROGLYCERIN 0.3 mg--11 tablet(s) sublingually for chest pain;\n repeat x 1 after 5 minutes - HAS NEVER USED.\n RANITIDINE HCL 150 mg--1 tablet(s) by mouth daily\n Past medical history:\n Family history:\n Social History:\n - CLL - referred to heme/onc (( ), for anemia, leukocytosis,\n found on flow cytometry confirmed B-cell chronic lymphocytic\n leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia,\n splenomegaly), so no plan for treatment as of .\n - htn\n - asthma\n - hyperlipidemia\n - OA - left hip, knee, previously on vioxx.\n - tah/bso fibroids\n - glucose intolerance (not on meds, a1c 6.1->5.5)\n - glaucoma\n - cancer screening: colonoscopy on showed 2 adenomatous\n polyps, one in the transverse colon and the other in the\n descending colon. Annual mammographies have been negative last in \n NC\n Occupation: lived near , primary caregiver husband\n Drugs: none\n Tobacco:\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss, night sweats\n Eyes: tinnitus\n Ear, Nose, Throat: No(t) Dry mouth, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: Joint pain, No(t) Myalgias, chronic knee\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Daytime\n somnolence\n Signs or concerns for abuse : No\n Pain: Minimal\n Flowsheet Data as of 04:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 91 (91 - 97) bpm\n BP: 106/56(68) {99/56(68) - 116/58(71)} mmHg\n RR: 24 (23 - 26) insp/min\n SpO2: 97% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 430 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -430 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, R axillary LAD\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender: R\n LQ, Obese, impressive splenomegally\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: all 4 ext\n Sedated, No(t) Paralyzed, Tone: normal\n Labs / Radiology\n 229 K/uL\n 25.9 %\n 8.7 g/dL\n 26.3 K/uL\n 12:53 PM\n WBC\n 26.3\n Hct\n 25.9\n Plt\n 229\n Other labs: ALT / AST:15/44, Alk Phos / T Bili:68/1.2\n Microbiology: blood and urine cx's sent\n ECG: lad nsr at 91, no acute changes and unchanged from prior\n CXR : Left lower lobe opacity, later shown to represent partial\n left lower lobe collapse on subsequent abdominal CT. The mediastinal\n adenopathy is not well appreciated on the chest radiograph.\n 2. Persistent left pleural effusion.\n CT abd and pelvis :\n 1. widely metastatic disease including bladder tumor, peritoneal\n implants, pulmonary mass/adenopathy, mediastinal adenopathy. While\n metastatic bladder is most likely, other ddx includes metastatic\n ovarian given distribution of metastatic disease, or other unknown\n primary.\n 2. Marked splenomegaly with two 1 cm hypodense lesions, indeterminate\n but also suspicious\n 3. partial collapse .\n 4. nonocclusive RLL pulmonary embolism.\n Assessment and Plan\n 85 yo F w/ CLL presents with hematuria and abd pain and transient\n hypotension in ED, found to have extensive masses throughout abd and\n pelvis/bladder concerning for widely metastatic disease of unclear\n primary and partially collapse and PE\n # Transient hypotension\nrelated to medication effect form morphine\n verses blood loss, PE, and less likely sepsis/infection from urine,\n post-obstructive pna,\n HD stable after 2 L IVF\n Infection w/u underway continuing empiric antibx with levo flagyl\n Serial h/h\ntransfusing for further Hct drop, keep activetype and\n cross and follow Q 8 hour cbc\n Large bore piv access\n # PE--stable from hemodynamic and respiratory standpoint and feel is\n high risk for anticoaglation given extensive masses hematuria and h/h\n drop\n IR for IVC filter placement\n #CLL/malignancy--primary site unclear--? Bladder, breast, renal cell\n ca, less likely CLL with progression, has had normal mammograms and\n polyps on recent colonoscopy\n pursue tissue diagnosis--urology c/s and onc input\n # uric acid elevation--etiology unclear but question of tumor\n lysis, renal fx stable and other lytes stable, continue hydration,\n follow tumor lysis labs\n # LFT abnormalities with elevated t bili-check hemolyisis labs,\n trend LFTs, DAT, check smear\n #? post-obstructive pna--f/u ct chest to further asses lung\n involvement, stable on 2 L NC\n continue empiric antbx with levo flagyl, broadening coverage if\n worsening respiratory or clinical status\n # leukocytosis--difficult to interpret in setting of CLL--reactive\n verses infection-trending down though significantly increased from\n baseline, onc c/s, follow and check differential, infection w/u as\n noted, c diff\n #abd pain--multiple masses throughout abdomen likely etiology, continue\n empiric antibx and pain control\n #hematuria--TWF--clear urine, irrigate if clots, h/h monitoring and\n transfusion as above\n # HTN--holding home meds given hypotension in ed\n Remainder per resident note, agree with plan as documented\n ICU Care\n Nutrition:\n Comments: NPO for IV filter placement\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR/DNI (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2125-02-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318123, "text": "Chief Complaint: Hematuria, cough, abdominal pain\n 24 Hour Events:\n - transfused 1 unit pRBCs\n - IVC filter placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37\nC (98.6\n HR: 86 (78 - 97) bpm\n BP: 108/50(66) {95/50(61) - 119/65(73)} mmHg\n RR: 16 (16 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 415 mL\n 2 mL\n PO:\n TF:\n IVF:\n 40 mL\n 2 mL\n Blood products:\n 375 mL\n Total out:\n 730 mL\n 300 mL\n Urine:\n 730 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale, No(t) Sclera edema, non-reactive,\n surgical pupils\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: L base)\n Abdominal: Bowel sounds present, Distended, Tender:\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 222 K/uL\n 9.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 113 mEq/L\n 144 mEq/L\n 29.0 %\n 24.1 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n WBC\n 26.3\n 21.6\n 24.1\n Hct\n 25.9\n 24.9\n 29.0\n Plt\n \n Cr\n 0.6\n 0.6\n Glucose\n 105\n 97\n Other labs: PT / PTT / INR:13.8/25.5/1.2, ALT / AST:17/46, Alk Phos / T\n Bili:66/1.7, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.2 g/dL, Ca++:8.2\n mg/dL, Mg++:1.8 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CANCER (MALIGNANT NEOPLASM), OTHER\n HYPOXEMIA\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n hematuria\n ASTHMA\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused.\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - serial HCT for today, q8h.\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n - LENIs to consider IVC filter, consider CTA, as would be useful to\n better characterize thoracic lymphadenopathy in terms best site for\n biopsy.\n - ?heparin, consider hold off on anticoag for now given stable\n respiratory status, and ?hemodynamically significant bleeding.\n .\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - CTA to characterize PE, also to characterize thoracic lymphadenoapthy\n and metastasis with regard to potential biopsy sites, will switch to\n high res CT chest tommorow as will place IVC filter empirically given\n that hct is dropping and prefer to avoid anticoagulation for tonight.\n - continue levo/flagyl, broaden if looks ill.\n - consider heparin gtt after CTA, hematuria stable presently\n - check sputum cx.\n .\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, could be hemolysis, no liver lesions on CT.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - tylenol, ultram prn for abd pain, would use 0.5-1mg morphine for abd\n pain if needed, though would be cautious given BP drop in ED.\n - hyperbilirubinemia may be hemolysis, no biliary dilation on CT,\n no RUQ pain.\n - fractionate bilirubin.\n .\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - place 3 way foley.\n - continuous bladder irrigation.\n - urology consult re biopsy of bladder mass.\n - hold aspirin.\n - cycle hct q8hr today.\n .\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, ddx also\n includes hemolysis.\n - trend LFTs.\n - fractionate bili, check smear, haptoglobin, DAT.\n .\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , could represent hemolysis.\n - heme/onc consult.\n - fractionate bilirubin, check haptoglobin, LDH, platelets smear, DAT\n - d/w team best site for tissue biopsy.\n - elevated uric acid, ?tumor lysis-> will continue gentle IVF\n hydration, follow uric acid, phos, ca.\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - npo for now, though biopsy unlikely, then diabetic diet.\n .\n #PPx\n - pneumoboots after LENIs, ppi.\n - bowel regimen prn.\n .\n #CODE: DNR/DNI, d/w pt and her son.\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-02-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318128, "text": "Chief Complaint: hematuria, transient hypotension, abd pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n received 1 units PRBC with appropraite bump\n IVC filter placed\n abd pain controlled with low dose morphine\n History obtained from Patient, house staff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37\nC (98.6\n HR: 91 (78 - 97) bpm\n BP: 117/61(75) {95/50(61) - 119/65(75)} mmHg\n RR: 22 (16 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 415 mL\n 122 mL\n PO:\n 120 mL\n TF:\n IVF:\n 40 mL\n 2 mL\n Blood products:\n 375 mL\n Total out:\n 730 mL\n 340 mL\n Urine:\n 730 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -218 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), P2, no RV strain\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: b/b)\n Abdominal: Soft, Distended, Tender: to palpation, no R/G\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 222 K/uL\n 97 mg/dL\n 0.6 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 12 mg/dL\n 113 mEq/L\n 144 mEq/L\n 29.0 %\n 24.1 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n WBC\n 26.3\n 21.6\n 24.1\n Hct\n 25.9\n 24.9\n 29.0\n Plt\n \n Cr\n 0.6\n 0.6\n Glucose\n 105\n 97\n Other labs: PT / PTT / INR:13.8/25.5/1.2, ALT / AST:17/46, Alk Phos / T\n Bili:66/1.7, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.2 g/dL, Ca++:8.2\n mg/dL, Mg++:1.8 mg/dL, PO4:3.3 mg/dL\n Imaging: chest ct ordered\n Assessment and Plan\n 85 yo F w/ CLL presents with hematuria and abd pain and transient\n hypotension in ED, found to have extensive masses throughout abd and\n pelvis/bladder concerning for widely metastatic disease of unclear\n primary and partially collapse and PE\n Main issues remain:\n # Transient hypotension\nrelated to medication effect form morphine\n verses blood loss, PE, and less likely sepsis/infection from urine,\n post-obstructive pna, now resolved\n most likely seconddary to med effect from morphine and\n hypovolemia, approp bump in h/h post 1 unit--trend\n Infection w/u underway and continuing empiric antibx with levo\n flagyl\n # Hypoxia--\n # PE--stable from hemodynamic and respiratory standpoint and\n feel is high risk for anticoaglation given extensive masses hematuria\n and h/h drop\n Had IVC filter placed yesterday\n IR for IVC filter placement,\n Echo to assess RV fx\n #? post-obstructive pna--f/u ct chest to further asses lung\n involvement, stable on 2 L NC\n continue empiric antbx with levo flagyl, broadening coverage if\n worsening respiratory or clinical status\n # Cough--tessalon perles, robitussion, flovent\n #CLL/malignancy\nnow with widely metastatic cancer with primary site\n unclear--? Bladder, breast, renal cell ca, less likely CLL with\n progression, has had normal mammograms and polyps on recent\n colonoscopy\n Pursue tissue/cytologic diagnosis--urology c/s and onc input,\n continue urine samples for cytology, feel that bladder mass is large\n and of high risk for resection\n Chest ct to further eval for lung involvement , reasses for\n possible post-obstructive/extrinsic compression\n Discuss with radiology regarding possible ct-guided FNA basef on\n CT findings\n # anemia--hct below baseline and will follow, now post 1 unit\n prbc's and stable bump, likely has low level hemolysis though based on\n lab findings not overwhelming, continue to follow\n # uric acid elevation--etiology unclear but question of tumor\n lysis, renal fx remains stable and other lytes stable, continue\n hydration and follow tumor lysis labs\n # LFT abnormalities with elevated t bili-DAT pending, habto < 20,\n check smear\n # leukocytosis--difficult to interpret in setting of CLL--reactive\n verses infection-trending down toward prior baseline,\n onc c/s, following, infection w/u as noted, c diff\n #abd pain--multiple masses throughout abdomen likely etiology, continue\n empiric antibx and pain control with morphine\n #hematuria--TWF--good urine outpt without clot not requiring urine\n irrigatation\n h/h monitoring and transfusion as above, Q 3 hr urine cytology\n ordered\n # HTN--holding home meds given hypotension in ed\n # Asthma--home meds\n Remainder per resident note, agree with plan as documented\n ICU Care\n Nutrition:\n Comments: advance for diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor if h/h remain stable on next lab check\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2125-02-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318323, "text": "Chief Complaint: hematuria and abd pain\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:11 AM\n - called out to ONC\n - urine cytology pending\n - hct stable\n Allergies:\n Ultram (Oral) (Tramadol Hcl)\n dissociative re\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 09:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.5\nC (97.7\n HR: 87 (77 - 98) bpm\n BP: 95/50(60) {94/50(60) - 119/83(92)} mmHg\n RR: 24 (22 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,810 mL\n 782 mL\n PO:\n 720 mL\n TF:\n IVF:\n 1,090 mL\n 782 mL\n Blood products:\n Total out:\n 1,000 mL\n 185 mL\n Urine:\n 1,000 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 810 mL\n 597 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Breath sounds diminshed at\n L base\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 191 K/uL\n 9.1 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 145 mEq/L\n 26.8 %\n 17.6 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n 10:15 AM\n 03:10 AM\n WBC\n 26.3\n 21.6\n 24.1\n 17.6\n Hct\n 25.9\n 24.9\n 29.0\n 29.9\n 26.8\n Plt\n 91\n Cr\n 0.6\n 0.6\n 0.7\n Glucose\n 105\n 97\n 129\n Other labs: PT / PTT / INR:14.1/26.8/1.2, ALT / AST:15/36, Alk Phos / T\n Bili:61/1.3, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.0 g/dL, LDH:640 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:1.9 mg/dL\n Imaging: CT of chest:\n 1. Subcarinal nodal mass.\n 2. Mass in the left infrahilar region with post- obstructive\n atelectasis,\n which has progressed to near left lower lobe collapse.\n 3. Marked left axillary lymphadenopathy, amenable to biopsy.\n 4. Somewhat larger bilateral pleural effusions.\n 5. Collapsibility of the trachea suggesting tracheomalacia.\n 6. Coronary artery calcifications.\n 7. Multiple abnormal masses in the upper abdomen, better depicted on\n the\n recent abdominal CT. The only new finding is trace ascites.\n 8. Known pulmonary embolism not visualized given the lack of contrast\n administration. The extent of pulmonary emboli, accordingly, cannot be\n assessed.\n TTE:\n The left atrium is elongated. Left ventricular wall thicknesses and\n cavity size are normal. Left ventricular systolic function is\n hyperdynamic (EF>75%). There is a mild resting left ventricular outflow\n tract obstruction. The gradient increased with the Valsalva manuever.\n Right ventricular chamber size and free wall motion are normal. The\n ascending aorta is mildly dilated. The aortic valve leaflets are mildly\n thickened. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Trivial mitral regurgitation is seen. There is\n moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Hyperdynamic left ventricular function with mild left\n ventricular outflow tract obstruction. No significant valvular\n disease.\n Microbiology: BCx Pending x 2\n Assessment and Plan\n A/P:\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused.\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - serial HCT for today, q8h.\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n - LENIs to consider IVC filter, consider CTA, as would be useful to\n better characterize thoracic lymphadenopathy in terms best site for\n biopsy.\n - ?heparin, consider hold off on anticoag for now given stable\n respiratory status, and ?hemodynamically significant bleeding.\n - upon further discussion, and repeat HCT falling, will place IVC\n filter and hold off on heparin for now.\n .\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - CTA to characterize PE, also to characterize thoracic lymphadenoapthy\n and metastasis with regard to potential biopsy sites.\n - continue levo/flagyl, broaden if looks ill.\n - consider heparin gtt after CTA, hematuria stable presently\n - check sputum cx.\n .\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, could be hemolysis, no liver lesions on CT.\n - obtain tissue -> will biopsy bladder mass in AM.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - tylenol, ultram prn for abd pain, would use 0.5-1mg morphine for abd\n pain if needed, though would be cautious given BP drop in ED.\n - hyperbilirubinemia may be hemolysis, no biliary dilation on CT,\n no RUQ pain.\n - fractionate bilirubin.\n .\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - place 3 way foley.\n - continuous bladder irrigation.\n - urology consult re biopsy of bladder mass.\n - hold aspirin.\n - cycle hct q8hr today.\n .\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, ddx also\n includes hemolysis.\n - trend LFTs.\n - fractionate bili, check smear, haptoglobin, DAT.\n .\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , could represent hemolysis.\n - heme/onc consult.\n - fractionate bilirubin, check haptoglobin, LDH, platelets smear, DAT\n - d/w team best site for tissue biopsy.\n - elevated uric acid, ?tumor lysis-> will continue gentle IVF\n hydration, follow uric acid, phos, ca.\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - npo for now, though biopsy unlikely, then diabetic diet.\n .\n #PPx\n - pneumoboots after LENIs, ppi.\n - bowel regimen prn.\n .\n #CODE: DNR/DNI, d/w pt and her son.\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-02-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 318198, "text": "85yo female with PMH CLL, not previously requiring treatment, who\n presented to EW with persistent abd. pain & hematuria starting\n . Other PMH sig for anemia, HTN, hyperlipidemia, asthma, glucose\n intolerance, L knee osteoarthritis.\n NKDA\n CT of abd/pelvis showed multiple new metastasis and new mass in\n bladder. Also RLL PE. Pt. transferred to MSICU for further work-up.\n IVC filter placed as anticoagulation not an option at this time\n d/t bleeding tumor in bladder.\n Pt. hemodynamically stable. c/o some abd. Pain but eases with prn\n morphine. No blood noted in urine since ICU admit.\n After discussion with pt & family pt DNR/DNI.\n Hypotension (not Shock)\n Assessment:\n BP 98-117/58-64, HR 77-91 NSR. No VEA noted. UO 20-45 cc hr. Afeb\n Action:\n Monitoring BP, HR, UO, temp\n Response:\n Stable. Called out to floor. No bed.\n Plan:\n Continue to monitor BP, HR, UO, temp\n Hypoxemia\n Assessment:\n RR 20\ns. Denies SOB, sats mid to high 90\ns on 2L NP, BS clear. Positive\n non-productive cough. Robitussin given X1. Receiving atrovent nebs\n Q6hrs\n Action:\n Weaned O2 to 2l Np with stable sats\n Response:\n Stable\n Plan:\n Sputum for C&S. Benzonatate, Guifenesin-codeine Phosphate PRN\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Denies abd except with palpation. Not requesting pain medication. No\n blood noted in urine.\n Action:\n Chest CT scan. Urine for cytology sent q3 hrs\n Response:\n Results pnd\n Plan:\n Cont to obtain urine cytology overnight. Check with urology in AM. Onc\n following. Morphine sulfate PRN for pain.\n Pt\ns son in to visit throughout the day. Dtr in to visit as well. Pt &\n family updated on plan of care. , social service met with\n family as well.\n" }, { "category": "Physician ", "chartdate": "2125-02-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318261, "text": "Chief Complaint: hematuria and abd pain\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:11 AM\n - called out to ONC\n - urine cytology pending\n - hct stable\n Allergies:\n Ultram (Oral) (Tramadol Hcl)\n dissociative re\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 09:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.5\nC (97.7\n HR: 87 (77 - 98) bpm\n BP: 95/50(60) {94/50(60) - 119/83(92)} mmHg\n RR: 24 (22 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,810 mL\n 782 mL\n PO:\n 720 mL\n TF:\n IVF:\n 1,090 mL\n 782 mL\n Blood products:\n Total out:\n 1,000 mL\n 185 mL\n Urine:\n 1,000 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 810 mL\n 597 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), Breath sounds diminshed at\n L base\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 191 K/uL\n 9.1 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 109 mEq/L\n 145 mEq/L\n 26.8 %\n 17.6 K/uL\n [image002.jpg]\n 12:53 PM\n 07:45 PM\n 02:47 AM\n 10:15 AM\n 03:10 AM\n WBC\n 26.3\n 21.6\n 24.1\n 17.6\n Hct\n 25.9\n 24.9\n 29.0\n 29.9\n 26.8\n Plt\n 91\n Cr\n 0.6\n 0.6\n 0.7\n Glucose\n 105\n 97\n 129\n Other labs: PT / PTT / INR:14.1/26.8/1.2, ALT / AST:15/36, Alk Phos / T\n Bili:61/1.3, Amylase / Lipase:/21, Differential-Neuts:21.0 %, Band:5.0\n %, Lymph:67.0 %, Mono:4.0 %, Eos:0.0 %, Albumin:3.0 g/dL, LDH:640 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:1.9 mg/dL\n Imaging: CT of chest:\n 1. Subcarinal nodal mass.\n 2. Mass in the left infrahilar region with post- obstructive\n atelectasis,\n which has progressed to near left lower lobe collapse.\n 3. Marked left axillary lymphadenopathy, amenable to biopsy.\n 4. Somewhat larger bilateral pleural effusions.\n 5. Collapsibility of the trachea suggesting tracheomalacia.\n 6. Coronary artery calcifications.\n 7. Multiple abnormal masses in the upper abdomen, better depicted on\n the\n recent abdominal CT. The only new finding is trace ascites.\n 8. Known pulmonary embolism not visualized given the lack of contrast\n administration. The extent of pulmonary emboli, accordingly, cannot be\n assessed.\n TTE:\n The left atrium is elongated. Left ventricular wall thicknesses and\n cavity size are normal. Left ventricular systolic function is\n hyperdynamic (EF>75%). There is a mild resting left ventricular outflow\n tract obstruction. The gradient increased with the Valsalva manuever.\n Right ventricular chamber size and free wall motion are normal. The\n ascending aorta is mildly dilated. The aortic valve leaflets are mildly\n thickened. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. Trivial mitral regurgitation is seen. There is\n moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion.\n IMPRESSION: Hyperdynamic left ventricular function with mild left\n ventricular outflow tract obstruction. No significant valvular\n disease.\n Microbiology: BCx Pending x 2\n Assessment and Plan\n A/P:\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused.\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - serial HCT for today, q8h.\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n - LENIs to consider IVC filter, consider CTA, as would be useful to\n better characterize thoracic lymphadenopathy in terms best site for\n biopsy.\n - ?heparin, consider hold off on anticoag for now given stable\n respiratory status, and ?hemodynamically significant bleeding.\n - upon further discussion, and repeat HCT falling, will place IVC\n filter and hold off on heparin for now.\n .\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - CTA to characterize PE, also to characterize thoracic lymphadenoapthy\n and metastasis with regard to potential biopsy sites.\n - continue levo/flagyl, broaden if looks ill.\n - consider heparin gtt after CTA, hematuria stable presently\n - check sputum cx.\n .\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, could be hemolysis, no liver lesions on CT.\n - obtain tissue -> will biopsy bladder mass in AM.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - tylenol, ultram prn for abd pain, would use 0.5-1mg morphine for abd\n pain if needed, though would be cautious given BP drop in ED.\n - hyperbilirubinemia may be hemolysis, no biliary dilation on CT,\n no RUQ pain.\n - fractionate bilirubin.\n .\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - place 3 way foley.\n - continuous bladder irrigation.\n - urology consult re biopsy of bladder mass.\n - hold aspirin.\n - cycle hct q8hr today.\n .\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, ddx also\n includes hemolysis.\n - trend LFTs.\n - fractionate bili, check smear, haptoglobin, DAT.\n .\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , could represent hemolysis.\n - heme/onc consult.\n - fractionate bilirubin, check haptoglobin, LDH, platelets smear, DAT\n - d/w team best site for tissue biopsy.\n - elevated uric acid, ?tumor lysis-> will continue gentle IVF\n hydration, follow uric acid, phos, ca.\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - npo for now, though biopsy unlikely, then diabetic diet.\n .\n #PPx\n - pneumoboots after LENIs, ppi.\n - bowel regimen prn.\n .\n #CODE: DNR/DNI, d/w pt and her son.\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-02-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 318269, "text": "85yo female with PMH CLL, not previously requiring treatment, who\n presented to EW with persistent abd. pain & hematuria starting\n . Other PMH sig for anemia, HTN, hyperlipidemia, asthma, glucose\n intolerance, L knee osteoarthritis.\n NKDA\n CT of abd/pelvis showed multiple new metastasis and new mass in\n bladder. Also RLL PE. Pt. transferred to MSICU for further work-up.\n IVC filter placed as anticoagulation not an option at this time\n d/t bleeding tumor in bladder.\n Pt. hemodynamically stable. c/o some abd. Pain but eases with prn\n morphine. No blood noted in urine since ICU admit.\n After discussion with pt & family pt DNR/DNI.\n Hypotension (not Shock)\n Assessment:\n BP 98-117/58-64, HR 77-91 NSR. No VEA noted. UO 20-45 cc hr. Afeb\n Action:\n Monitoring BP, HR, UO, temp\n Response:\n Stable. Called out to floor. No bed.\n Plan:\n Continue to monitor BP, HR, UO, temp\n Hypoxemia\n Assessment:\n RR 20\ns. Denies SOB, sats mid to high 90\ns on 2L NP, BS clear. Positive\n non-productive cough. Robitussin given X1. Receiving atrovent nebs\n Q6hrs\n Action:\n Weaned O2 to 2l Np with stable sats\n Response:\n Stable\n Plan:\n Sputum for C&S. Benzonatate, Guifenesin-codeine Phosphate PRN\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Denies abd except with palpation. Not requesting pain medication. No\n blood noted in urine.\n Action:\n Chest CT scan. Urine for cytology sent q3 hrs\n Response:\n Results pnd\n Plan:\n Cont to obtain urine cytology overnight. Check with urology in AM. Onc\n following. Morphine sulfate PRN for pain.\n Pt\ns son in to visit throughout the day. Dtr in to visit as well. Pt &\n family updated on plan of care. , social service met with\n family as well.\n ------ Protected Section ------\n Demographics\n Attending MD:\n Admit diagnosis:\n METASTATIC CANCER\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 70.3 kg\n Daily weight:\n Allergies/Reactions:\n Ultram (Oral) (Tramadol Hcl)\n dissociative re\n Precautions:\n PMH: Asthma\n CV-PMH: Hypertension\n Additional history: CLL dx'd in , hyperlipidemia, OA of L hip&\n knee, glucose intol (not on home meds), glaucoma.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:72\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,487 mL\n 24h total out:\n 243 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:10 AM\n Potassium:\n 3.7 mEq/L\n 03:10 AM\n Chloride:\n 109 mEq/L\n 03:10 AM\n CO2:\n 30 mEq/L\n 03:10 AM\n BUN:\n 14 mg/dL\n 03:10 AM\n Creatinine:\n 0.7 mg/dL\n 03:10 AM\n Glucose:\n 129 mg/dL\n 03:10 AM\n Hematocrit:\n 26.8 %\n 03:10 AM\n Finger Stick Glucose:\n 147\n 06:00 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n foley cath\n 2 PIVs\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cane\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 406\n Transferred to: R 1264\n Date & time of Transfer: 12:00 AM\n ------ Protected Section Addendum Entered By: , RN\n on: 10:28 ------\n" }, { "category": "Physician ", "chartdate": "2125-02-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 318051, "text": "Chief Complaint: hematuria, cough, abdominal pain\n HPI:\n 85 F h/o stage 0 CLL, not requring tx previously, presents to ED for\n persistent cough/abdominal pain, and hematuria.\n .\n Pt notes ~2 mo increasing fatigue, nightsweats, n, decreased appetite,\n and increasing left side abdominal pain (intermittent, no relation to\n food, BM, sharp, no diarrhea, constipation, melena). She was seen by\n PCP , felt to have viral URI, symptoms persisted, and seen again\n with persistent cough (intermittently productive,\n yellow-white), single episode of hematuria (clear red, not clot), and\n LLQ abdominal pain, treated with azithromycin, and abdominal USN\n obtained which revealed new splenomegaly with new 1.5-cm echogenic\n area.\n .\n On , pt noted recurrent episode of \"strong blood in urine.\"\n Describes clear red +clots, +feeling incomplete voiding, no suprapubic\n pain, no CVA tenderness. Also notes R LE pain.\n .\n Pt presented to the ED with VS: 98.1 79 113/69 16 100%RA. In the\n ED, CXR with LUL collapse, CT ABD/PELVIS with multiple new metastasis,\n and new mass in bladder. also RLL PE. UA +hematuria, + UTI. pt given\n levo, flagyl, morphine 2mg x3 for pain. BP then noted to drop to\n 70/37, pt received total 2L IVF, although timing unclear, with BP\n improved to 102/55s (?dehyration vs sepsis vs morphine). No central\n line placed. CT head obtained in anticipation of possible\n anticoagulation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - CLL - referred to heme/onc (( ), for anemia, leukocytosis,\n found on flow cytometry confirmed B-cell chronic lymphocytic\n leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia,\n splenomegaly), so no plan for treatment as of .\n - htn\n - asthma\n - hyperlipidemia\n - OA - left hip, knee, previously on vioxx.\n - tah/bso fibroids.\n - glucose intolerance (not on meds, a1c 6.1->5.5)\n - glaucoma\n - cancer screening: colonoscopy on showed 2 adenomatous\n polyps, one in the transverse colon and the other in the\n descending colon. Annual mammographies have been negative.\n she lives with her husband. They have 2 children, 1 son and 1\n daughter, in their 50s and 60s, respectively.\n - worked as a pharmacist in , . She was 80 miles from the\n Chernobyl accident in , leaving on the 3rd day of the radiation\n exposure, although she's not certain if she was in fact exposed to\n radiation. 3 months later, she returned to her residence. Some of her\n co-workers had thyroid concerns after the Chernobyl\n accident. She moved to the U.S. in .\n .\n No family history of hematologic or oncologic dyscrasias. Both parents\n died of strokes. A sister, her only\n sibling, had \"pancreatic\" obstruction, not cancer related, and died at\n age 64. The patient's daughter had breast cancer at age 54.\n Occupation: retired\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: lives with huband, indepdent of adls, worked as pharmacist in\n , 80mi from chernobyl accident in , left area on 3rd day of\n radiation exposure, returned 3 mo later.\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: tinnitus\n Respiratory: Cough, Dyspnea\n Gastrointestinal: Abdominal pain, Nausea\n Heme / Lymph: Lymphadenopathy\n Flowsheet Data as of 03:03 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 91 (91 - 97) bpm\n BP: 106/56(68) {99/56(68) - 116/58(71)} mmHg\n RR: 24 (23 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 430 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -430 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical adenopathy, axillary adenopathy (R), left inguinal\n adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: LLL)\n Abdominal: Soft, Bowel sounds present, Distended, +splenomegaly\n ~5inches below cv angle\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): person, place, t\n ime., Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 229 K/uL\n 8.7 g/dL\n 25.9 %\n 26.3 K/uL\n [image002.jpg]\n \n 2:33 A2/28/ 12:53 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 26.3\n Hct\n 25.9\n Plt\n 229\n Other labs: ALT / AST:15/44, Alk Phos / T Bili:68/1.2\n Assessment and Plan\n 85F russian, CLL, presenting with cough, abd pain, and hematuria, found\n to have LUL collapse LAD, multiple abdominal mets, and new bladder\n mass.\n .\n # hypotension - resolving, ddx includes hypovolemia (blood loss,\n dehydration) vs sepsis vs PE vs morphine. ANC > 1000, thus atypical\n infxns unlikely. feel more likely medication vs sepsis. BP stable\n presently, low 100s, mentating well, well perfused.\n - follow UOP, prn bolus for UOP <30cc/hr (EF >55%).\n - T&S.\n - serial HCT for today, q8h.\n - f/u bcx, ucx, consider sputum cx.\n - continue levo/flagyl for now, consider broadening for\n post-obstructive cvg only if looks ill.\n - LENIs to consider IVC filter, consider CTA, as would be useful to\n better characterize thoracic lymphadenopathy in terms best site for\n biopsy.\n - ?heparin, consider hold off on anticoag for now given stable\n respiratory status, and ?hemodynamically significant bleeding.\n .\n .\n # hypoxia - +cough, new LLL collapse likely 2/2 L hilar lymphadenopathy\n with resulting post-obstructive colapse, +LLL effusion, ?RLL increased\n opacification, also ?contribution from RLL PE (?old), not completely\n characterized on CT ABD/PELVIS. no EKG changes concerning for MI, no\n evidence of CHF. currently on 2L O2, breathing comfortably.\n - CTA to characterize PE, also to characterize thoracic lymphadenoapthy\n and metastasis with regard to potential biopsy sites.\n - continue levo/flagyl, broaden if looks ill.\n - consider heparin gtt after CTA, hematuria stable presently\n - check sputum cx.\n .\n .\n # abdominal pain - multiple new omental, peritoneal, mesenteric, and\n retroperitoneal metastases, GE jxn mass, LUQ mass, primary unclear\n (bladder vs ovarian, though s/p tah/bso), concerning for new metastatic\n malignancy. also increased splenomegaly. elevated tbil (2.1), though\n AP normal, could be hemolysis, no liver lesions on CT.\n - trend LFTs, no evidence of bil dil on CT, consider RUQ USN if\n trending up.\n - tylenol, ultram prn for abd pain, would use 0.5-1mg morphine for abd\n pain if needed, though would be cautious given BP drop in ED.\n - hyperbilirubinemia may be hemolysis, no biliary dilation on CT,\n no RUQ pain.\n - fractionate bilirubin.\n .\n .\n # hematuria - new bladder mass on CT scan, 400cc UOP in ED, ~100-200cc\n on arrival to . has had clots in urine per pt. creatinine\n stable.\n - place 3 way foley.\n - continuous bladder irrigation.\n - urology consult re biopsy of bladder mass.\n - hold aspirin.\n - cycle hct q8hr today.\n .\n .\n # leukocytosis - likely CLL vs infection.\n - treat with abx as above, discuss plan for CLL with heme-onc.\n .\n # hyperbilirubinemia - no ruq pain, no biliary dilation on CT, ddx also\n includes hemolysis.\n - trend LFTs.\n - fractionate bili, check smear, haptoglobin, DAT.\n .\n .\n # CLL - baseline hct 35-36, plt 200s, splenomegaly now increased, new\n mediastinal lymphadenopathy. new bladder mass. +hyperbil, though\n haptoglobin+, DAT negative in , could represent hemolysis.\n - heme/onc consult.\n - fractionate bilirubin, check haptoglobin, LDH, platelets smear, DAT\n - d/w team best site for tissue biopsy.\n - elevated uric acid, ?tumor lysis-> will continue gentle IVF\n hydration, follow uric acid, phos, ca.\n .\n # htn - hold home antihypertensives given hypotension and hematuria.\n .\n # asthma - continue home meds.\n .\n # hyperlipidemia - continue home statin.\n .\n # OA - left hip, knee, tx with prn tylenol (max 2g/day given elevated\n LFTs).\n .\n # glucose intolerance - follow FSBS here, cover with , d/c if\n not requring insulin.\n .\n #FEN\n - npo for now, though biopsy unlikely, then diabetic diet.\n .\n #PPx\n - pneumoboots after LENIs, ppi.\n - bowel regimen prn.\n .\n #CODE: DNR/DNI, d/w pt and her son.\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: h-, cell .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: IVC filter\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-02-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 318057, "text": "Chief Complaint: abd pain and hematuria wioth transient hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo F with stable CLL, not requring treatment, presents to ed with\n abd pain, hemturia also with several month h/o f/ns\n seen by pcp with viral uri sx with persisted--return to PCP \n for more sputum production, also had noted 1 episode of hematuria and\n ongoin L LQ pelvic/abd pain. Treated with azithro for presumed\n CAP/bronchitis and noted to have increase in WBC to 40 from baseline\n 20's and prbc in urine. Abd u/s showed splenomegaly with new\n echogenic spelnic lesion. au/a ith hematuria\n Yesterday had icnreaed hematuria now with clots with sense of\n incomplete voiding, no cva pain or suprapubic pain prompting ED visit.\n COugh ongoing though unchanged X past week and abd pain at baseline.\n Also notes tinnitus, new since . No CP, SOB, syncope, no emesis or\n nausea\n to ed for hematuria and abd discomfort. the cough\n ct abd and pelvis--with multiple masses at blasser, RLL pe and LLL\n collapse with hilar LAD seen on lung bases\n levo and flagyl started for possible post-obstructive pna verses GI\n infection. Transient hypotension to 70/30 after 6 of mkorphine with\n respoinse to 2 L IVF. transferred to ICU for furtehr care\n cxr--lower lobe collapse\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records,\n housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALBUTEROL 17 GM--Take 2 puff twice a day as needed\n AMBIEN 10MG--One by mouth at bedtime as needed\n ASPIRIN 81 MG--One by mouth every day\n ATENOLOL 25 mg--1. tablet(s) by mouth once a day - NOT TAKING.\n Atorvastatin 10 mg--0.5 tablet(s) by mouth once a day\n CLONAZEPAM 0.5 mg--one tablet(s) every evening as needed\n COSOPT 0.5 %-2 %--1 gtt os twice a day to LEFT EYE\n COZAAR 50 mg--1 tablet(s) by mouth once a day\n Citalopram 20 mg--0.5 tablet(s) by mouth at bedtime\n Flovent HFA 110 mcg/Actuation--take 2 puffs twice a day\n HYDROCHLOROTHIAZIDE 12.5MG--Take one by mouth daily\n LORATADINE 10 mg--1 tablet(s) by mouth once a day as needed for\n congestion, ear discomfort (itching)\n NITROGLYCERIN 0.3 mg--11 tablet(s) sublingually for chest pain;\n repeat x 1 after 5 minutes - HAS NEVER USED.\n RANITIDINE HCL 150 mg--1 tablet(s) by mouth daily\n Past medical history:\n Family history:\n Social History:\n - CLL - referred to heme/onc (( ), for anemia, leukocytosis,\n found on flow cytometry confirmed B-cell chronic lymphocytic\n leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia,\n splenomegaly), so no plan for treatment as of .\n - htn\n - asthma\n - hyperlipidemia\n - OA - left hip, knee, previously on vioxx.\n - tah/bso fibroids\n - glucose intolerance (not on meds, a1c 6.1->5.5)\n - glaucoma\n - cancer screening: colonoscopy on showed 2 adenomatous\n polyps, one in the transverse colon and the other in the\n descending colon. Annual mammographies have been negative last in \n NC\n Occupation: lived near , primary caregiver husband\n Drugs: none\n Tobacco:\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss, night sweats\n Eyes: tinnitus\n Ear, Nose, Throat: No(t) Dry mouth, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley\n Musculoskeletal: Joint pain, No(t) Myalgias, chronic knee\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Daytime\n somnolence\n Signs or concerns for abuse : No\n Pain: Minimal\n Flowsheet Data as of 04:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 91 (91 - 97) bpm\n BP: 106/56(68) {99/56(68) - 116/58(71)} mmHg\n RR: 24 (23 - 26) insp/min\n SpO2: 97% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 430 mL\n Urine:\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -430 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, R axillary LAD\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender: R\n LQ, Obese, impressive splenomegally\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 229 K/uL\n 25.9 %\n 8.7 g/dL\n 26.3 K/uL\n [image002.jpg]\n 12:53 PM\n WBC\n 26.3\n Hct\n 25.9\n Plt\n 229\n Other labs: ALT / AST:15/44, Alk Phos / T Bili:68/1.2\n Microbiology: blood and urine cx's sent\n ECG: lad nsr at 91, no acute changes and unchanged from prior\n Assessment and Plan\n 85 yo F w/ CLL presents with\n # Hypotension--likely from medication effect though blood loss from\n hematuria, infection--urine, post-obstructive pna, pe could contribute,\n stable after 2 L IVF,\n infection w/u underway and empiric antibx\n follow h/h--if continues to drop would transfuse, keep active\n tuype and cross, Q 8 hour cbc\n access- now with 2 PIV's\n #? post-obstructive pna--f/u ct chest to further asses, continue\n emperic antbx with levo flagyl, broadening coverage\n # PE--stable from hemodynamic standpoint and respiratory standpoint and\n feel is high risk for anticoaglatiomn given bladder elsion and h/h\n drop--IR for IVC filter palcement--has been AF\n # leukocytosis--difficult to interpret in setting of CLL--reactive\n verses infection-trending down\n #abd pain--multiple masses throughout abdomen likely etiology, continue\n emperic antibx,\n # malignancy--primary site unclear--? bladder, less liekly CLL with\n progression, has had normal mammograms\n pursue tissue diagnosis--urology c/s, also with\n #hematuria--TWF--clear urine, would irrigate if clots\n # LFT abnormalities--check hmolyisis labs, trend LFTs\n # pain--ultram, low dose morphine\n # uric acid elevation--etiology unlcear but question of tumor lysis,\n renal fx stable and other lytews stable, continue hydration, follow\n tumor lysis labs\n HtN--holding home meds given hypotension in ed\n asthma--continue flovent\n chol--statin\n OA--pain meds, ultram/tyleonol\n ICU Care\n Nutrition:\n Comments: NPO for IV filter placement\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n" }, { "category": "Nursing", "chartdate": "2125-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318240, "text": "Cancer (Malignant Neoplasm), Other\n Assessment:\n Abd softly distended and tender on palpation. Urine amber in color,\n cloudy. CT of abd and pelvis showed new metastasis and new bladder\n mass. u/o marginal. Urine amber and cloudy.\n Action:\n Urine sent for cytology q3hr, last spec sent at 0300.\n Response:\n Results currently pending.\n Plan:\n Onc is following pt, check with urology. Morphine for pain as needed.\n Hypoxemia\n Assessment:\n RR 22-27, with slight sob noted on exertion. Lungs have remained clear\n with sao2 93-96% range.\n Action:\n Pt on atrovent nebs and flovent inhaler. Remains on n/c.\n Response:\n Remains stable.\n Plan:\n Cont to monitor resp status and provide nebs and inhalers as needed. Pt\n is called out to the floor awaiting a bed.\n" } ]

[ { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542814, "text": "53 y/o male admitted to EW with acute intoxication. Pt showing s/s of\n ETOH withdrawal and therefore sent to ICU for close monitoring.\n Today pt\ns potassium and magnesium repleted . C/O to floor, awaiting\n bed.\n Delirium / confusion\n Assessment:\n CIWA ranging from today. Pt sleeping intermittently throughout the\n day. No acute agitation/anxiety noted.\n Action:\n CIWA checked q 2-3 hours. Pt given valium 10mg for score >10. Pt\n given one time dose of 20 mg. total Valium dose this shift 40mg.\n Response:\n Pt with some minimal s/s withdrawal\n Plan:\n Continue to monitor CIWA\n Hypertension, benign\n Assessment:\n Pt hypertensive throughout the day.\n Action:\n Lopressor dose increased to 25mg TID.\n Response:\n Pt remains hypertensive.\n Plan:\n ? need to increase dose\n" }, { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542817, "text": "53 y/o male admitted to EW with acute intoxication. Pt showing s/s of\n ETOH withdrawal and therefore sent to ICU for close monitoring.\n Today pt\ns potassium and magnesium repleted . C/O to floor, awaiting\n bed.\n Delirium / confusion\n Assessment:\n CIWA ranging from today. Pt sleeping intermittently throughout the\n day. No acute agitation/anxiety noted.\n Action:\n CIWA checked q 2-3 hours. Pt given valium 10mg for score >10. Pt\n given one time dose of 20 mg. total Valium dose this shift 40mg.\n Response:\n Pt with some minimal s/s withdrawal\n Plan:\n Continue to monitor CIWA,CIWA at 9pm-4,last dose of Valium 10 mg at\n 1800\n Hypertension, benign\n Assessment:\n Pt hypertensive throughout the day.\n Action:\n Lopressor dose increased to 25mg TID.\n Response:\n Pt remains hypertensive.\n Plan:\n ? need to increase dose\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n ETOH WITHDRAWAL\n Code status:\n Height:\n Admission weight:\n 98 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH, Hepatitis, Seizures\n CV-PMH: Hypertension\n Additional history: Pt. is homeless. Has had multiple EW admissions\n for ETOH abuse. Has had seizures in the past with DT's.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:160\n D:117\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 3,712 mL\n 24h total out:\n 3,970 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:22 AM\n Potassium:\n 3.6 mEq/L\n 05:22 AM\n Chloride:\n 96 mEq/L\n 05:22 AM\n CO2:\n 28 mEq/L\n 05:22 AM\n BUN:\n 6 mg/dL\n 05:22 AM\n Creatinine:\n 0.7 mg/dL\n 05:22 AM\n Glucose:\n 74 mg/dL\n 05:22 AM\n Hematocrit:\n 36.6 %\n 05:22 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent with pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 410\n Transferred to: 11R 65\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 542818, "text": "53 y/o male admitted to EW with acute intoxication. Pt showing s/s of\n ETOH withdrawal and therefore sent to ICU for close monitoring.\n Today pt\ns potassium and magnesium repleted\n Delirium / confusion\n Assessment:\n CIWA ranging from today. Pt sleeping intermittently throughout the\n day. No acute agitation/anxiety noted.\n Action:\n CIWA checked q 2-3 hours. Pt given valium 10mg for score >10. Pt\n given one time dose of 20 mg. total Valium dose this shift 40mg.\n Response:\n Pt with some minimal s/s withdrawal\n Plan:\n Continue to monitor CIWA,CIWA at 9pm-4,last dose of Valium 10 mg at\n 1800\n Hypertension, benign\n Assessment:\n Pt hypertensive throughout the day.\n Action:\n Lopressor dose increased to 25mg TID.\n Response:\n Pt remains hypertensive.\n Plan:\n ? need to increase dose\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n ETOH WITHDRAWAL\n Code status:\n Height:\n Admission weight:\n 98 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH, Hepatitis, Seizures\n CV-PMH: Hypertension\n Additional history: Pt. is homeless. Has had multiple EW admissions\n for ETOH abuse. Has had seizures in the past with DT's.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:160\n D:117\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 3,712 mL\n 24h total out:\n 3,970 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:22 AM\n Potassium:\n 3.6 mEq/L\n 05:22 AM\n Chloride:\n 96 mEq/L\n 05:22 AM\n CO2:\n 28 mEq/L\n 05:22 AM\n BUN:\n 6 mg/dL\n 05:22 AM\n Creatinine:\n 0.7 mg/dL\n 05:22 AM\n Glucose:\n 74 mg/dL\n 05:22 AM\n Hematocrit:\n 36.6 %\n 05:22 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent with pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 410\n Transferred to: 11R 65\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2184-10-16 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 542661, "text": "Chief Complaint: alcohol withdrawal\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 53 y/o man admitted to ED Obs after acute alcohol intoxication (429,\n last drink yest evening). Initially did well but developed HTN and\n tachycardia --> ICU admit for withdrawal.\n Pt notes that he wishes to be sober for his mother's upcoming 80th\n birthday.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 04:00 PM\n Other medications:\n Per patient:\n Hydrochlorothiazide 25mg daily\n atenolol 50mg daily\n dilantin 300mg daily\n Past medical history:\n Family history:\n Social History:\n alcohol abuse\n alcohol withdrawl c/b seizures\n HCV\n HTN\n Occupation:\n Drugs: quiescent history of IVDU, cocaine/crack use\n Tobacco: < 1ppd for many years\n Alcohol: ongoing\n Other: lives in . PCP is . , healthcare\n for the homeless.\n Review of systems:\n Constitutional: Fatigue, diaphoretic\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain\n Flowsheet Data as of 05:25 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 68 (68 - 78) bpm\n BP: 170/110(124) {167/110(124) - 172/120(127)} mmHg\n RR: 12 (12 - 17) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 907 mL\n PO:\n 500 mL\n TF:\n IVF:\n 407 mL\n Blood products:\n Total out:\n 0 mL\n 900 mL\n Urine:\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 7 mL\n Respiratory\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Extremities: Right: Absent edema, Left: Absent edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, Tone: Normal\n Labs / Radiology\n Labs reviewed in OMR. Notable for mild pancytopenia, hypokalemia.\n Assessment and Plan\n 53-year-old man with\n alcohol withdrawl\n - IV thiamine\n - folate\n - oral Valium based on CIWA\n - Follow alcohol withdrawal protocol\n - Consult substance abuse counseling\n pancytopenia\n - likely nutritional: replete\n seizure disorder\n - continue home dilantin\n - check dilantin level\n hypertension\n - resume home meds\n hypokalemia\n - replete\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 01:41 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2184-10-16 00:00:00.000", "description": "Resident admission note", "row_id": 542662, "text": "TITLE:\n Resident Admission Note\n .\n Reason for MICU Admission: Nursing requirement for CIWA scale\n .\n Primary Care Physician: , MD\n .\n CC: .\n HPI: This is a 53year-old male with a history of Etoh abuse w/h/o\n seizures w/withdrawal who presented w/acute etoh intoxication to the ED\n 1 day PTA. His initial Etoh level was 429 w/last drink day 1 day PTA.\n He drink 2 bottles of vodka daily. He was observed overnight in the ED\n and appeared to be stable until this AM when he became hypertensive and\n tachycardic.\n .\n In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He received\n Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM and once at 10AM)\n per CIWA scale which was started this AM.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity\n oedema, cough, urinary frequency, urgency, dysuria, lightheadedness,\n gait unsteadiness, focal weakness, vision changes, headache, rash or\n skin changes.\n .\n Past Medical History:\n -Alcohol abuse h/o withdrawal c/b seizures\n -Hypertension\n -Hepatitis C\n -Seizure disorder\n Medications:\n Hydrochlorothiazide 25mg daily\n atenolol 50mg daily\n dilantin 300mg daily\n .\n Allergies: NKDA\n .\n Social History: Smokes a few cigarettes a day x many years. Heavy\n alcohol history, about 1pint vodka a day now. History IVDU,\n cocaine/crack use Multiple unprotected female partners.\n Homeless, living at shelter. Mainly around Circle. PCP\n is . , healthcare for the homeless. Lives\n with sister in when sober. Works in trucking when\n sober. He was born in , worked as a chef. He finished High\n School\n .\n Family Medical History: NC\n .\n Physical Exam:\n Vitals: T 99.4 : BP 170/110 : HR 80 : RR 17 : O2Sat: 97% RA\n GEN: anxiouse appearing, well-nourished, in obviouse distress\n HEENT: EOMI, PERRL, no epistaxis or rhinorrhea, MMM, OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, no cervical\n lymphadenopathy, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords, +tremor\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\n disturbance. No cerebellar dysfunction.\n SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.\n .\n .\n .\n Assesment: This is a 53 year-old male with a history of alcohol abuse\n who presents with with acute intoxication\n .\n Plan:\n # Alcohol withdrawal: last drink 1 day PTA ; has h/o seizures\n associated w/withdrawal\n - po valium CIWA scale q1 hours\n - MVI/thiamine/folate\n - SW consult\n - aspiration precautions\n .\n # h/o hepatitis C: no serologies in our system: will check LFT, coags,\n and hep C serology\n .\n # pancytopenia: most likely due to alcohol abuse leading to vit\n deficiency. to be w/u as outpatient once off IV MV\n .\n # HTN: resume atenolol, will hold off HCTZ due to hypokalemia\n .\n # FEN: regular diet with hydration\n .\n # Access: peripheral\n .\n # PPx: s.c. heparin\n .\n # Code: full\n .\n # Dispo: pending <CIWA requiriment\n .\n # Comm:\n" }, { "category": "Physician ", "chartdate": "2184-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 542721, "text": "Chief Complaint:\n 24 Hour Events:\n - Currently 36 hrs since last drink\n - Required 60 mg valium since admit\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 66 (64 - 78) bpm\n BP: 171/116(127) {167/92(114) - 180/121(132)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,208 mL\n 1,065 mL\n PO:\n 1,500 mL\n 250 mL\n TF:\n IVF:\n 1,708 mL\n 815 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,550 mL\n Urine:\n 1,350 mL\n 1,550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,858 mL\n -485 mL\n Respiratory support\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n DELIRIUM / CONFUSION\n HYPERTENSION, BENIGN\n 53 year-old male with a history of alcohol abuse who presents with with\n acute intoxication\n .\n Plan:\n # Alcohol withdrawal: last drink 1 day PTA ; has h/o seizures\n associated w/withdrawal\n - po valium CIWA scale q1 hours\n - MVI/thiamine/folate\n - SW consult\n - aspiration precautions\n .\n # h/o hepatitis C: Transaminases elevated\n - avoid hepatotoxic medications\n - Max of 2g tylenol per day\n .\n # pancytopenia: most likely due to alcohol abuse leading to vit\n deficiency. to be w/u as outpatient once off IV MV\n .\n # HTN: resume atenolol, will hold off HCTZ due to hypokalemia\n .\n # FEN: regular diet with hydration\n .\n # Access: peripheral\n .\n # PPx: s.c. heparin\n .\n # Code: full\n .\n # Dispo: pending <CIWA requiriment\n .\n # Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542715, "text": "HPI: This is a 53year-old male with a history of Etoh abuse w/h/o\n seizures w/withdrawal who presented w/acute etoh intoxication to the ED\n 1 day PTA. His initial Etoh level was 429 w/last drink day 1 day PTA.\n He drink 2 bottles of vodka daily. He was observed overnight in the ED\n and appeared to be stable until this AM when he became hypertensive and\n tachycardic.\n .\n In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He received\n Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM and once at 10AM)\n per CIWA scale which was started this AM.\n Delirium / confusion\n Assessment:\n CIWA scale range 8-13. Pt. is alert and oriented X3 and able to\n describe sensations,pt afebrile continued to be hypertensive sats 95%\n on RA\n Action:\n Valium per CIWA scale received valium 10 mg Q2-3 hrs,metoprolol 12.5\n mg/PO given\n Response:\n CIWA score decreases with valium.last dose was at 0530\n Plan:\n CIWA scale q 1 hour\n On - po valium for CIWA greater than 10.\n Maintain IV hydration in addition to po intake\n require to adjust the lopressor dose.\n" }, { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542707, "text": "HPI: This is a 53year-old male with a history of Etoh abuse w/h/o\n seizures w/withdrawal who presented w/acute etoh intoxication to the ED\n 1 day PTA. His initial Etoh level was 429 w/last drink day 1 day PTA.\n He drink 2 bottles of vodka daily. He was observed overnight in the ED\n and appeared to be stable until this AM when he became hypertensive and\n tachycardic.\n .\n In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He received\n Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM and once at 10AM)\n per CIWA scale which was started this AM.\n Delirium / confusion\n Assessment:\n CIWA scale range 8-13. Pt. is alert and oriented X3 and able to\n describe sensations,pt afebrile continued to be hypertensive\n Action:\n Valium per CIWA scale received valium 10 mg Q2-3 hrs,metoprolol 12.5\n mg/PO given\n Response:\n CIWA score decreases with valium\n Plan:\n CIWA scale q 1 hour\n On - po valium for CIWA greater than 10.\n Maintain IV hydration in addition to po intake\n require to adjust the lopressor dose.\n" }, { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542789, "text": "53 y/o male admitted to EW with acute intoxication. Pt showing s/s of\n ETOH withdrawal and therefore sent to ICU for close monitoring.\n Today pt\ns potassium and magnesium repleted . C/O to floor, awaiting\n bed.\n Delirium / confusion\n Assessment:\n CIWA ranging from today. Pt sleeping intermittently throughout the\n day. No acute agitation/anxiety noted.\n Action:\n CIWA checked q 2-3 hours. Pt given valium 10mg for score >10. Pt\n given one time dose of 20 mg. total Valium dose this shift 40mg.\n Response:\n Pt with some minimal s/s withdrawal\n Plan:\n Continue to monitor CIWA\n Hypertension, benign\n Assessment:\n Pt hypertensive throughout the day.\n Action:\n Lopressor dose increased to 25mg TID.\n Response:\n Pt remains hypertensive.\n Plan:\n ? need to increase dose\n" }, { "category": "Nursing", "chartdate": "2184-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542690, "text": "HPI: This is a 53year-old male with a history of Etoh abuse w/h/o\n seizures w/withdrawal who presented w/acute etoh intoxication to the ED\n 1 day PTA. His initial Etoh level was 429 w/last drink day 1 day PTA.\n He drink 2 bottles of vodka daily. He was observed overnight in the ED\n and appeared to be stable until this AM when he became hypertensive and\n tachycardic.\n .\n In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He received\n Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM and once at 10AM)\n per CIWA scale which was started this AM.\n Delirium / confusion\n Assessment:\n CIWA scale range 8-22. Pt. is alert and able to describe sensations of\n DT\n Action:\n Valium per CIWA scale\n Response:\n CIWA score decreases with valium\n Plan:\n CIWA scale q 1 hour\n Switched to po valium for CIWA greater than 10.\n Maintain IV hydration in addition to po intake\n" }, { "category": "Nursing", "chartdate": "2184-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542678, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542679, "text": "HPI: This is a 53year-old male with a history of Etoh abuse w/h/o\n seizures w/withdrawal who presented w/acute etoh intoxication to the ED\n 1 day PTA. His initial Etoh level was 429 w/last drink day 1 day PTA.\n He drink 2 bottles of vodka daily. He was observed overnight in the ED\n and appeared to be stable until this AM when he became hypertensive and\n tachycardic.\n .\n In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He received\n Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM and once at 10AM)\n per CIWA scale which was started this AM.\n Delirium / confusion\n Assessment:\n CIWA scale range 8-22. Pt. is alert and able to describe sensations of\n DT\n Action:\n Valium per CIWA scale\n Response:\n CIWA score decreases with valium\n Plan:\n CIWA scale q 1 hour\n Switched to po valium for CIWA greater than 10.\n Maintain IV hydration in addition to po intake\n Hypertension, benign\n Assessment:\n hypertensive\n Action:\n Started on atenolol\n Response:\n Just received first dose\n Plan:\n Monitor BP\n" }, { "category": "Nursing", "chartdate": "2184-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 542680, "text": "HPI: This is a 53year-old male with a history of Etoh abuse w/h/o\n seizures w/withdrawal who presented w/acute etoh intoxication to the ED\n 1 day PTA. His initial Etoh level was 429 w/last drink day 1 day PTA.\n He drink 2 bottles of vodka daily. He was observed overnight in the ED\n and appeared to be stable until this AM when he became hypertensive and\n tachycardic.\n .\n In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He received\n Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM and once at 10AM)\n per CIWA scale which was started this AM.\n Delirium / confusion\n Assessment:\n CIWA scale range 8-22. Pt. is alert and able to describe sensations of\n DT\n Action:\n Valium per CIWA scale\n Response:\n CIWA score decreases with valium\n Plan:\n CIWA scale q 1 hour\n Switched to po valium for CIWA greater than 10.\n Maintain IV hydration in addition to po intake\n Hypertension, benign\n Assessment:\n hypertensive\n Action:\n Started on atenolol\n Response:\n Just received first dose\n Plan:\n Monitor BP\n" }, { "category": "Physician ", "chartdate": "2184-10-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 542752, "text": "Chief Complaint: alcohol withdrawal\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n no major events overnight. Received 50mg Valium overnight.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:00 AM\n Other medications:\n Valium, folate, thiamine, multivitamin, lopressor\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 10:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 69 (64 - 90) bpm\n BP: 160/117(126) {160/92(114) - 180/122(135)} mmHg\n RR: 18 (12 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,208 mL\n 2,061 mL\n PO:\n 1,500 mL\n 740 mL\n TF:\n IVF:\n 1,708 mL\n 1,321 mL\n Blood products:\n Total out:\n 1,350 mL\n 2,210 mL\n Urine:\n 1,350 mL\n 2,210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,858 mL\n -149 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: no edema, Left: no edema\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 12.1 g/dL\n 146 K/uL\n 74 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 96 mEq/L\n 137 mEq/L\n 36.6 %\n 3.7 K/uL\n [image002.jpg]\n 05:22 AM\n WBC\n 3.7\n Hct\n 36.6\n Plt\n 146\n Cr\n 0.7\n Glucose\n 74\n Other labs: PT / PTT / INR:12.6/32.8/1.1, Ca++:7.4 mg/dL, Mg++:1.1\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 53-year-old man with\n alcohol withdrawl\n IV thiamine\n folate\n oral Valium based on CIWA. Valium requirement has\n decreased.\n Follow alcohol withdrawal protocol\n Consult substance abuse counseling\n pancytopenia\n likely nutritional: replete vitamins and follow\n seizure disorder\n will review his anti-epileptic drugs with is PCP. \n is pretty convincing, including hx of trauma\n check dilantin level. If not toxic, resume dilantin.\n be reasonable to consider Keppra for him as an\n alternative drug. Will review with PCP.\n \n need to increase Lopressor. Hold on HCTZ given\n hypokalemia.\n ?fluid wave on exam, and hx of HCV\n Check ultrasound to exclude ascites\n need further evaluation\n Transaminitis\n Likely secondary to alcohol + HCV\n Follow for now.\n Electrolyte abnormalities\n Replete\n ICU Care\n Nutrition: oral diet\n Glycemic Control:\n Lines:\n 20 Gauge - 01:41 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2184-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 542739, "text": "Chief Complaint:\n 24 Hour Events:\n - Currently 36 hrs since last drink\n - Required 50 mg valium since admit\n - CIWA for last 4 hrs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 66 (64 - 78) bpm\n BP: 171/116(127) {167/92(114) - 180/121(132)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,208 mL\n 1,065 mL\n PO:\n 1,500 mL\n 250 mL\n TF:\n IVF:\n 1,708 mL\n 815 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,550 mL\n Urine:\n 1,350 mL\n 1,550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,858 mL\n -485 mL\n Respiratory support\n SpO2: 94%\n ABG: ////\n Physical Examination\n Gen: NAD, AOx3\n HEENT: EOMI, no lateral nystagmus, minimal tongue fasiculations\n CV- RRR no m/r/g\n Pulm- CTAB\n Abd- Mild distention, NT, soft, small fluid wave\n Extr- Fine tremor with arms outstretched, none while resting\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n DELIRIUM / CONFUSION\n HYPERTENSION, BENIGN\n 53 year-old male with a history of alcohol abuse who presents with with\n acute intoxication\n .\n Plan:\n # Alcohol withdrawal: last drink 1 day PTA ; has h/o seizures\n associated w/withdrawal. Currently improved with CIWA\ns less than 10 x\n 4 hrs.\n - po valium CIWA scale q1 hours\n - MVI/thiamine/folate\n - SW consult\n - aspiration precautions\n .\n # h/o hepatitis C: Transaminases elevated\n - avoid hepatotoxic medications\n - Max of 2g tylenol per day\n .\n # pancytopenia: most likely due to alcohol abuse leading to vit\n deficiency. to be w/u as outpatient once off IV MV\n .\n # HTN: resume atenolol, will hold off HCTZ due to hypokalemia\n .\n # FEN: regular diet with hydration\n .\n # Access: peripheral\n .\n # PPx: s.c. heparin\n .\n # Code: full\n .\n # Dispo: pending <CIWA requiriment\n .\n # Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2184-10-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 542757, "text": "Chief Complaint:\n 24 Hour Events:\n - Currently 36 hrs since last drink\n - Required 50 mg valium since admit\n - CIWA for last 4 hrs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 66 (64 - 78) bpm\n BP: 171/116(127) {167/92(114) - 180/121(132)} mmHg\n RR: 13 (12 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,208 mL\n 1,065 mL\n PO:\n 1,500 mL\n 250 mL\n TF:\n IVF:\n 1,708 mL\n 815 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,550 mL\n Urine:\n 1,350 mL\n 1,550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,858 mL\n -485 mL\n Respiratory support\n SpO2: 94%\n ABG: ////\n Physical Examination\n Gen: NAD, AOx3\n HEENT: EOMI, no lateral nystagmus, minimal tongue fasiculations\n CV- RRR no m/r/g\n Pulm- CTAB\n Abd- Mild distention, NT, soft, small fluid wave\n Extr- Fine tremor with arms outstretched, none while resting\n Labs / Radiology\n [image002.jpg]\n See OMR\n Assessment and Plan\n DELIRIUM / CONFUSION\n HYPERTENSION, BENIGN\n 53 year-old male with a history of alcohol abuse who presents with with\n acute intoxication\n .\n Plan:\n # Alcohol withdrawal: last drink 1 day PTA ; has h/o seizures\n associated w/withdrawal. Currently improved with CIWA\ns less than 10 x\n 4 hrs.\n - po valium CIWA scale change to q2 hours\n - MVI/thiamine/folate\n - SW consult\n - aspiration precautions\n .\n # Seizure disorder: Patient states he is on dilantin as outpatient but\n his pills were stolen 2 weeks ago\n - check dilantin level\n - Restart home dose\n - Call PCP ? keppra vs dilantin\n .\n # h/o hepatitis C: Transaminases elevated\n - U/S abd to look for ascites.\n - avoid hepatotoxic medications\n - Max of 2g tylenol per day\n .\n # pancytopenia: most likely due to alcohol abuse leading to vit\n deficiency. to be w/u as outpatient once off IV MV\n .\n # HTN: Likely combination of essential HTN and withdrawal\n -titrate Metoprolol for now,\n -will hold off HCTZ for now\n .\n # FEN: regular diet with hydration\n .\n # Access: peripheral\n .\n # PPx: s.c. heparin\n .\n # Code: full\n .\n # Dispo: pending <CIWA requiriment\n .\n # Comm: with patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" } ]

[ { "category": "Radiology", "chartdate": "2141-03-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1005075, "text": " 6:31 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with lupus and RF here with severe HTN\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST DATED .\n\n HISTORY: 73-year-old woman with renal failure, here with severe hypertension;\n rule out failure.\n\n FINDINGS: Two views are compared with most recent study dated . In\n the interval, the ET and endogastric tubes and central venous catheter via IVC\n approach have been removed. There is now patchy retrocardiac opacity largely\n obscuring that hemidiaphragm, new. The remainder of the lungs is essentially\n clear. The cardiomediastinal silhouette and pulmonary vessels are unchanged,\n with no pleural effusion.\n\n IMPRESSION:\n 1. Patchy retrocardiac opacity, new, which may simply represent atelectasis;\n early pneumonic infiltrate cannot be excluded.\n 2. No CHF.\n\n" }, { "category": "ECG", "chartdate": "2141-03-27 00:00:00.000", "description": "Report", "row_id": 170454, "text": "Sinus rhythm. Left ventricular hypertrophy with secondary repolarization\nchanges. Poor R wave progression could be due to left ventricular hypertrophy.\nCompared to the previous tracing of the T wave inversions in leads V4-V6\nare less pronounced and there are new T wave inversions in leads I and aVL.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-28 00:00:00.000", "description": "Report", "row_id": 1261639, "text": "Update\nSee careview for details...\nPt from ED for HTN, admit to MICU service\nNeuro: Pt 3, MAE, c/o h/A, tylenol po given\n\nCV: BP 140's on arrival, labetolol gtt turned off, MICU team at bedside to assess pt, NSR 70's\n\nResp: LC, tol RA, sats 100%\n\nGI: tol po's, slight nausea on arrival, subsided shortly after\n\nplan: Monitor BP overnight, transfer to or d/c home in AM\n" }, { "category": "Nursing/other", "chartdate": "2141-03-28 00:00:00.000", "description": "Report", "row_id": 1261640, "text": "Nursing PRogress Note\nPlease see carvue for specifics:\n\nPt okay to d/c per MICU resident . Pt was below baseline 140 in afternoon post antihypertensives. Pt between 97-105's and pt felt dizzy. Pt ate dinner and began to rise to 120's and pt felt better. MICU team made aware and pt okay to go home. Pt is to see primary MD tomorrow at the atrium\n" } ]

[ { "category": "Radiology", "chartdate": "2155-04-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 786576, "text": " 3:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with type I DM x 20 years p/w N/V in DKA\n h/o CHF, retinopathy, renal disease\n REASON FOR THIS EXAMINATION:\n acute SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes. Patient in DTA with history of CHF and currently with\n shortness of breath.\n\n CHEST, PORTABLE:\n\n COMPARISON: Three weeks prior.\n\n FINDINGS: The cardiac silhouette appears slightly enlarged compard with the\n prior study. There is bilateral patchy alveolar opacity, predominantly at the\n lung bases, right greater than left. No pleural effusions or pneumothorax.\n Osseous structures are unremarkable.\n\n IMPRESSION: CHF. A superimposed infectious process right lower lobe cannot be\n excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-04-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 786854, "text": " 4:37 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for CHF, infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with DM, HTN, CHF s/p diuresis and ? RLL infiltrate on admit\n (and recent hx few weeks ago of effusion).\n REASON FOR THIS EXAMINATION:\n please evaluate for CHF, infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n , CHEST\n\n INDICATION: Diabetes, hypertension, CHF. Status post duresis. Right lower\n lobe infiltrate. Rule out CHF.\n\n FINDINGS: PA and left lateral views. Prior study dated . There\n has now been almost complete resolution of the right lower lobe and, to a\n lesser extent, the left lower lobe consolidation demonstrated at that time. No\n new pulmonary infiltrates are seen. There is blunting of the posterior\n costophrenic angles suggesting small bilateral effusions. Some residual\n linear atelectasis is noted at the left lung base posteriorly. The pulmonary\n vessels are within normal limits and there is no evidence of cardiac failure\n at this time.\n\n A small amount of free gas is noted beneath the diaphragm anteriorly and\n centrally. Is there any evidence of a ... ? needling ... procedure or\n surgical procedure below the diaphragm?\n\n IMPRESSION: Marked resolution of the previous bibasilar pulmonary\n consolidations and probable associated cardiac failure at that time. Residual\n bilateral small effusions and a small area of atelectasis at the left base.\n Some free air noted beneath the diaphragm, unexplained at this time.\n\n" }, { "category": "Radiology", "chartdate": "2155-04-12 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 787072, "text": " 1:08 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: check placement of pd catheter.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with pt with hiccups *12 hours with placement of peritoneal\n dialysis catheter yesterday\n REASON FOR THIS EXAMINATION:\n check placement of pd catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 year old male with hiccups 12 hours after replacement of a\n peritoneal dialysis catheter yesterday.\n\n FINDINGS: Supine and erect views of the abdomen show stool diffusely\n throughout the colon. No air fluid levels or dilated loops of bowel seen.\n Peritoneal dialysis catheter is seen coiled in the pelvis. No free air. No\n soft tissue abnormalities appreciated.\n\n IMPRESSION: No evidence of obstruction or free air.\n\n\n" }, { "category": "Echo", "chartdate": "2155-04-07 00:00:00.000", "description": "Report", "row_id": 67017, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 155\nBSA (m2): 1.87 m2\nBP (mm Hg): 122/64\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 15:51\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferior - akinetic; mid inferior - akinetic;\ninferior apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated. The aortic arch is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly depressed. Resting regional wall motion\nabnormalities include global hypokinesis with inferior and inferoseptal\nhypokinesis. Right ventricular chamber size and free wall motion are normal.\nThe ascending aorta is mildly dilated. The aortic valve leaflets are mildly\nthickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study of , there is a slight improvement in\noverall LV function.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-04-09 00:00:00.000", "description": "Report", "row_id": 1346891, "text": "NURSING NOTE: 7P-7A\n PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE. NO COMPLAINTS VOICED. MAE. FOLLOWS COMMANDS.\n\nRESP- LUNG SOUNDS CLEAR. RA SATS >95%. RR 14-18. NO RESP DISTRESS OVERNIGHT.\n\nCV- HR 80'S NSR NO ECTOPY NOTED. SBP 120-140'S. +PEDAL PULSES AND 1+ EDEMA. ANTIHYPERTENSIVE MEDS GIVEN AS ORDERED.\n\nGI- ABD SOFT POSITIVE BS. NO STOOL. KEPT NPO AFTER MIDNIGHT FOR PERITONEAL CATHETER PLACEMENT TODAY.\n\nGU/RENAL- VOIDING IN URINAL 400-600CC OF CLEAR YELLOW URINE AT A TIME.\nYESTERDAY'S BUN 113, CR 7.4. PT CONSENTED TO PERITONEAL DIALYSIS CATHETER PLACEMENT. PT STATES FAMILY MEMBERS BEING EVALUATED FOR POSSIBLE KIDNEY DONORS.\n\nENDO- FSBS AT 2200 WAS 209, GIVEN 8 U HUMOLG PER SLIDING SCALE. PT DENIES ANY HYPO/HYPERGLYCEMIC REACTIONS.\n\nACCESS- #18 LLA SITE WNL.\n\nSOCIAL- AT BEDSIDE LAST EVENING.\n\nDISPO/PLAN- REMAINS IN MICU, FULL CODE. CONTINUE TO MONITOR BLOOD SUGARS. PD CATHETER PLACEMENT SOME TIME TODAY. CONTINUE TOGIVE EMOTIONAL SUPPORT TO PATIENT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2155-04-09 00:00:00.000", "description": "Report", "row_id": 1346892, "text": "NSG UPDATED TRANSFER NOTE. MICU-B\nS/O: PLEASE SEE TRANSFER NOTE WRITTEN .\nC/V: BP-128-160/70, HR 70-80'S SR WITH NO ECTOPY, REC'ING SEVERAL PO ANTIHYPERTENSIVES, TOLERATING WELL.\n\nENDO: FS'- 150-180 TODAY, HAD BEEN NPO UNTIL PD CATH WAS PLACED. REC'D OF GLARGINE DOSE THIS AM 10UNITS INSTEAD OF 20U, BEING COVERED WITH HUMALOG S/S INSULIN. IS NOT FEELING WELL SO HAS NOT EATEN TOO MUCH TODAY JUST DIET GINGERALE AND CRACKERS.\n\nGU: BUN/CRE REMAIN HIGH, PD CATH PLACED IN OR THIS AM, TOLERATED PROCEDURE WELL, BUT HAS C/O'D ACUTE PAIN SINCE RETURN. HAS REC'D OXYCODONE PO WITH NO EFFECT, REC'D MSO4 2MG IV @ 1430, AWAITING RESPONSE. VOIDING USING URINAL WITH NO PROBLEMS.\n\nGI: AS ABOVE WAS NPO FOR PROCEDURE, BUT HAS NOT FELT WELL ENOUGH TO EAT SINCE RETURN FROM THE OR. HAS + BS,& IS SOFT AND THE PAIN IS FROM THE CATH PLACEMENT. MD HAS SEEN AND EXAMINED PT.\n\nID: NO TEMPS IS REC'ING ANTIBX'S FOR PNX.\n\nRESPIR: ON R/A WITH RR 10-15, O2 SATS ON RA- 93-99%. NO COUGH NOTED. L/S CLEAR.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-04-07 00:00:00.000", "description": "Report", "row_id": 1346887, "text": "NURSING PROGRESS NOTE 0700-1500\nPLS REFER TO NURSING TRANSFER NOTE IN \"NURSES TRANSFER NOTE \"SECTION OF CAREVIEW. THANKS.\n" }, { "category": "Nursing/other", "chartdate": "2155-04-07 00:00:00.000", "description": "Report", "row_id": 1346888, "text": "NPN-MICU\nHeme:pt recieved x1unit of PRBC's, tol well hct pnd from 6:45pm.\nHe also recieved x1 dose of 40mg of IVP lasix which he rsp with 60cc urine. He will cont on his usual does of pm lasix as well. He is off O2 with a sat of 98%, crackles at rt base only. His lytes and CK will also be checked at that time.\nGI/ENDO: his appetite is good and BS covered with humalog.\nCV: BP stable but low from him a t130's/ hr in the 80's\nA/P: stable post tx, tol of f O2\n Will check labs at 7pm and asses for signs od CHF\n Cont to follow BS\n" }, { "category": "Nursing/other", "chartdate": "2155-04-08 00:00:00.000", "description": "Report", "row_id": 1346889, "text": "Neuro: Pt. remains A/A/O and denies any pain or discomfort at this time. Pt. has remained afebrile during this shift.\n\nC.V: Pt. has been NSR in the 80's with no noted ectopy noted during this shift. B/P has been stable in the 120-130's over 40-60's. Pedal edema has decreased from +3-+1 pitting.\n\nResp: Pt. exhibited crackles in bilat bases, but cleared throughout shift. At present pt. remains clear and audible in all lung fields. Pt. had been 95-98% on R.A but while sleeping O2 sats dropped to 87%. O2 at 2l/min applied at this time.\n\nG.I: Pt. remians on diabetic diet, bowel sounds are easily audible in all quadrants, soft and non tender. Pt. was placed back on insulin gtt due to elevated blood glucose. And at present only remains on at .5 units per hour. Blood sugars have been stable.\n\nG.U: Pt. is voiding large amt's of clear yellow urine.\n\nI.V: Access remains 2 #18 gauges in left hand and forearm. These are excellent sites, with D5W infusing at 80cc hr.\n\nSkin: Benign\n" }, { "category": "Nursing/other", "chartdate": "2155-04-08 00:00:00.000", "description": "Report", "row_id": 1346890, "text": "MICU NPN 0700-1900\n\nREVIEW OF SYSTEMS:\nNEURO; pleasant, A/A/O, +MAE, OOB to chair with observation\n\nCV: HR 80's SR no VEA, BP 120-130's/60-70's, + peripheral edema,\ncont aggressive antihypertensives.\n\nRESP: lungs clear, o2 sat 97-99%, no SOB\n\nGI: ABD soft flat +BS no BM, eating diet, no GI c/o's\n\nENDO: labile FS glucose elevated glucose this am, requiring insulin gtt, noon changed to usual insulin 20U lantus and sliding scale humalog, 5pm FS 54 ate dinner 6p FS 174 given SS humalog.\n\nHEME: hct 30\n\nID: afebrile, cont azithro and ceftriax\n\nF/E: K 3.0 repleted see one time orders, 6p K 5.0, cr 7.4,\nplan for peritoneal dialysis catheter placement tomorrow.\n\nSOCIAL: sister and here throughout the day.\n\nPLAN: cont to follow fingersticks, cont to follow labs/lytes, called out to floor, transfer note written.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-04-07 00:00:00.000", "description": "Report", "row_id": 1346886, "text": "Neuro: Pt. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT AT THIS TIME. PT. IS AFEBRILE AT THIS TIME. PT. MOVES ALL EXTREMITIES AND PUPILS ARE EQUAL AND REACTIVE.\n\nC.V: PT. HAS REMAINED NSR IN THE 70-90'S WITH NO NOTED ECTOPY. B/P HAS BEEN STABLE RANGING 120-140'S OVER 50-70'S. PT. CONTINUES TO EXHIBIT +2 PITTING EDEMA TO BOTH LOWER EXTREMITIES. PT. TAKES LASIX AT HOME. BUN AND CREAT HAVE BEEN ELEVATED WITH C.R.I. AND PT. HAS BEEN EVALUATED FOR DIALYSIS IN THE PAST MONTH. PT. WAS TO BE SWANED DURING HIS ARRIVAL TO THE UNIT FROM THE EW. BUT, PT. STABLIZED QUICKLY AND TEAM RE EVALUATED TO HOLD FOR NOW.\n\nRESP: PT. HAD NOTED CRACKLES IN THE BASES UPON ARRIVAL TO THE UNIT. AFTER RECEIVING LASIX IN THE EW PT. DIURESED. NOW ALL LUNG SOUND ARE EASILY AUDIBLE AND HAVE REMAINED CLEAR FOR THE REMAINDER OF THIS SHIFT. PT. CONTINUES TO REQUIRE OXYGEN SUPPORT AND HAS BEEN ON 5L/MIN VIA NASAL CANNULA WHILE SATURATION RANGING 93-98%\n\nG.I: PT. IS ON DIABETIC DIET. INSULIN GTT WAS D/C'D AFTER FIRST 2HRS IN THE UNIT. BLOOD SUGARS HAVE RANGED 72-352 WITH SLIDING SCALE COVERAGE PROVIDED.\n\nG.U: PT. VOIDING WITHOUT DIFFICULTIES, AND URINE IS CLEAR. PT. HAS REFUSED CATHETER AT THIS POINT, BUT HE HAS BEEN EDUCATED ON THE POSSIBLITY OF NEEDING ONE AT A LATER DATE.\n\nI.V: PT. HAS 2 #18 GAUGE IN THE LEFT ARM WHICH ARE FUNCTIONING WELL.\n\nSKIN: BENIGN IN ASSESSMENT.\n" }, { "category": "ECG", "chartdate": "2155-04-06 00:00:00.000", "description": "Report", "row_id": 145207, "text": "Sinus rhythm. Left atrial enlargement. Q-T interval prolongation. Compared to\nthe previous tracing of no diagnostic interim change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2167-02-22 00:00:00.000", "description": "Report", "row_id": 1559417, "text": "Resp Care\n\nPt remains on full vent support. I/E ratio changed to 1:1 in effort to improve oxygenation. Fio2 require remains high at 70% to obtain Pao2 of 68. Will re-evaluate I/E ratio after follow abg.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-23 00:00:00.000", "description": "Report", "row_id": 1559418, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Attempted to wean Fentanyl as per HO because of hypotension. Wean to 400mcg/hr was unsucessful. Pt exhibited s/s of discomfort. HO aware. Fentanyl increased back to 500mcq/hr. Nimbex titrated secondary to increased resp efforts. Infusing at 0.75mg/kg/hr. HO aware. Train of four remains at 4/4 on 8ma of energy. B/L pupils 4mm, R sluggish, L brisk. +corneals. Pt remains unresponsive w/ no spon nor purposeful mobility.\n\nRESP: B/L BS diminished, coarse w/ rales throughout. OETT, Vent settings at start of shift; A/C/ 34/ .70/ 350/ 14. I:E at 1:1, ABG improved. PIP 50-60's, periods of desaturation; NMB titrated w/ some improvement, PIP in 40's. 0200 ABG; 7.18/80/63/31. Pt satting at 90. I:E reverted back to 1:1.5, rate increased to 36. 0430 ABG; 7.20/78/64/32. ABG w/ miniscule effect. Pt remains hypercarbic and hypoxic. FIO2 increased to 80% Satting at 98% Pulminary toileting Q2hr. Suctioned small-mod amt of thick yellow. Chest PT via bed. Tongue edematous. Oral airway inserted to prevent injury to tongue and to facilitate oral suctioning.\n\nCV: Pt in ST for most of the shift, rate 100-120. Afebrile. QRS 0.08 PR 0.18 QT. 0.38. Hypotensive at start of shift resolved w/ NS 1L bolus total. Neo started temporarily during this time and d/c'd. CVP 12-14. 0200 HCT=22.9. TX 1U PRBC, tolerated well, no s/s of an adverse reaction. Pt anasarcic throughout. I&O approx 3L positive for shift. All pulses via dopper. Skin warm, pale. AM K+=4.0, Mg+=2.0.\n\nGI: Abd more distended, possibly sec to third spacing. Trouble shooting implemented; no residuals, no gastric build-up via OGT, bladder pressures WNL, no urinary retention. Passing large amts of green, liquid . LFT this AM WNL. Hypoactive BS to BLQ. TPN at target. Tol peptamen TF at 20cc/hr via peditube; increasing slowly as per HO. Insulin gtt at 19U/hr to maintain BS 80-100.\n\nGU: Foley C/D/I, good urine output, patent.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-23 00:00:00.000", "description": "Report", "row_id": 1559419, "text": "pt.remains on ac ventilation , abg acidotic, recruitment breathe given earlier with no significant change, bs diminished, sx for thick white secretions with lavage, watch for increased pips, paralytics help. fi02 increased to 80%.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-27 00:00:00.000", "description": "Report", "row_id": 1559440, "text": " 0700 to 1900\nNeuro: Pt on Cisatracurium.28/mg/kg/hr. Train of 4, on 8ma of energy. Versed 30mg/hr, Fentanyl 500mcg/hr. Pt is non responsive to stimulation.\n\nResp: Vent CMV FIO2 70% Rate 36 vT 350 PEEP 22. Pt has required very little sx today. She is producing more oral secreations however. Lungs are clear in the bases with a few scattered crackles in the upper lobes bilat. Sats have remained 93 to 97% on present vent settings. Pt is afebrile. Continues on multiple abx. Please see .\n\nCV: HR was 130's through most of day. At approx 1500 HR dropped to 1teens an has remained there the rest of the afternoon. Rhythm is sinus. There has been no ectopy noted. MAP is 90's to 1teens. CVP 21.\n\nGU/GI: Foley is patent, draining urine >100ml/hr. Pt had large liquid BM at which time a mushroom cath was inserted rectally and pt continues to expel large amounts of . Tube feeds of Peptamen is running at 55/hr via post pyloric NG tube and pt is tolerating well.\n\nEndo: Pt is on an insulin gtt and per protocol is at a rate of 2.8u/hr. FS's have ranged 79 to 132.\n\nSocial: Pt has had several family members visit today. Family meeting scheduled for 1700 has been delayed as pt's mother has not arrived.\nThe Bank has been here all afternoon reviewing pt's file and at this time there is some question as to weather pt is elegable to donate organs due to her multiple organisms and hypoxemia.\n\nPlan: Meet with family tonigh to discuss plan of care and pt and famiy wishes. Pt is a DNR/DNI and husband states pt would not want everything she has been subjected to.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-14 00:00:00.000", "description": "Report", "row_id": 1559382, "text": "S/MICU Nursing Progress Note 7am-7pm\nSee Careview for Additional Objective Data\n#1:Respiratory Failure s/p polysubstance OD\nD:Remains intubated and mechanically ventilated with essentially full support. CXR:with worsening ARDS pattern Suctioning q 4-6 hours for small-mod amounts of thick white secreations BS:clear with diminished sounds at bases. SpO2 >95% on 60% FiO2\n Tmax:101.7 po WBC:9.3, no bands\n Abd:Obese, soft, non-tender with hypoactive BS. No stool OGT:small amounts of bilious fluid pH:5 OB+ NPO, receiving TPN\n BUN/Cr:30/.7 U/O:28-120cc/hr, decreasing over the course of the shift. I/O's from midnoc:+ approx. 2250cc CVP: (on PEEP of 10) IVF NS @ 150cc/hr\n Hemodynamically stable\n Am BS:267\n\nA:Vent settings changed:A/C 50/400/20 with PEEP:10, (lower volume with decrease in FiO2)\n D/C'ed steroids s/ stim test\n Cultured: BCx2, sputum. CT of Abd and Chest for tomorrow\n Added Imipenum to antibx regime\n Insulin gtt started\n IVFluid bolus for decreasing U/O\n NGT changed over to OGT\n\nR:ABG on new settings:78/37/7.38 with SpO2:93-95%, appears to have increased work of breathing with SRR:/min, tylenol for temps with good response, cultures:png,BS better controlled on low dose insulin gtt:112-118. Continue with supportive care, consider increasing resp rate to 30 to reduce work of breathing, continue to volume resusitate for decrease U/O in setting of possible pancreatitis\n" }, { "category": "Nursing/other", "chartdate": "2167-02-14 00:00:00.000", "description": "Report", "row_id": 1559383, "text": "Respiratory Care:\npt.remains on Mechanical Vent. as per CareVue.\nEvents of today : tv to 400cc for continued Lung protective stratagies, FiO2 to 40% due to a good PaO2, MDI's given with each vent check.\nPlan: continue to monitor and wean as pt. tolerates.\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-16 00:00:00.000", "description": "Report", "row_id": 1559391, "text": "resp care\npt remains intubated and mech ventilated. pt placed on pcv in effort to reduce dyssynchrony w/vent, some improvement noted. see carevue for settings. esophageal balloon placed w/o complication, optimal peep appears to be appx 15. pt tx to/from radiology and ct scan w/o incident. b/s sl coarse, w/sc crackles. sxn thk tan x1, otherwise wh secretions. plan: cont w/mech support, ? ^peep, ? ps trial to alleviate dyssynchrony.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-16 00:00:00.000", "description": "Report", "row_id": 1559392, "text": "pmicu nursing progress note\nresp: present vent settings are pressure control ventilation 50% x 30 vented breathes 10 peep and insp pressure of 30, with spont tvs of 300-360. an abg on these settings was 82 56 and 7.29. sx'd a couple of times for a small amt of thick white sputum. increased the fentanyl drip to 500mcgs/hr and the versed drip continues are 10mg/hr. pt doesn't appear to be visibly having asynchronise breathing as she did yesterday---appears to be comfortable. cxr--bil ill defined densities. lung sounds coarse with crackles and some expiratory wheezing. esophageal balloon placed today. down for chest c-scan with contrast. thick yellow (and some charcoal noted) drained from nose--receiving afrin. when pt turned to the left side down, pt initially dropped o2 sat.\n\ncardiac: bp 96-120/46-54 with a pulse of 75-87 sr, with no ectopy noted. k+ 4.1. cvp 9-18. lactated ringers infusing at 100cc/hr. good pedal pulses.\n\nid: temp at 8a was 100.9 ax and 102.2po. and at 1p temp was 100.3po received tylenol supp at approx 10a. imipenim. sputum sent for culture and gram stain. cooling blanket was placed under pt, but at present the blanket is off.\n\nendo: continues on the regular insulin drip--please see carevue for fingersticks obtained throughout the day. presently the drip is infusing at 2.5u/hr.\n\ngi: abdomin soft/distended, unable to hear bowel sounds. down for placement of a post pyloric feeding tube--to start on peptamen. og tube still in place (on low interm suction) as pt is still draining barocat (rec'd 2 bottles for prep) for abdominal ct. will remove og tube when no further aspirates are obtained. tpn infusing at 62.5cc/hr (checked with intern prior to hanging tpn with lipids). amylase, ldh, trigly, and alk phos all elevated\n\ngu: foley in place. output is approx 80-100cc/hr. bun 19 and creat .7.\n\nskin: raised rash noted on upper chest near neck. skin intact, although coccys/buttocks slightly red. ?? yeast rash in peri/anal area---nystatin powder placed.\n\nheme: hct 29.8.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-17 00:00:00.000", "description": "Report", "row_id": 1559393, "text": "O. Neuro sedated 500mcg/hr fentanyl and 10mg versed pupils +1 reactive no movement\nresp on PC 30 50% TV 380-419/10 peep/RR 30 abg 7.26/54/76/27/-1 PC increased 40 abg 7.29/54/76/27/-1 lungs rt clear lt coarse crackles bases o2 sat drop to 90-93% on rt side sx white thick sputum small amt\ncardiac Hct 26.3 cvp 4-5 ivf LR 100cc q hr, HR 76-90 nsr without ectopy K+ 3.9 mag 1.9 skin w+d pp+3 +2 edema extremities\nGu u/o >60cc BUN 17 cr .6\nGI abd obese soft BS+ postpyloric tube in pentamen started at 10cc increased to 20cc OGT cont LIS black bilious no stool TPN with lipids cont\nEndo insulin gtt increased to 5u q hr BS 155\naccess lt SC triple lumen, rt radial aline\nID temp max 102.7 on cooling blanket tylenol supp given wbc 7.0 on imipenem\nskin multiple areas of ecchymoisis on llq and legs along veins, groin area and abd folds erythematous nystatin applied\na. alt resp status asp pnx ARDS\ndrop hct\np. PC ventilation with low TV monitor closely maximize ventilation limit turns to rt, await cx reports, antibx as ordered\ncooling blanket prn, tylenol supp, monitor wbc await cx results\nguiac all stool recheck HCT monitor s+s blding\nmonitor BS q 1 hr adjust insulin\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-17 00:00:00.000", "description": "Report", "row_id": 1559394, "text": "Resp: pt on pcv dvp 20/+10/rr 30/50%. Bs auscultated reveal bilateral coarse apecies with diminished rs, some wheezes noted. Suctioned small amount of tan/whitish secretions. MDI's administered Q4 combivent. ABG's drawn (see careview) vent changes reflect. Present settings dvp ^ to 40. AM ABG's on present settings 7.29/54/76/27. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-17 00:00:00.000", "description": "Report", "row_id": 1559395, "text": "resp care\npt remains intubated and mech ventilated. see carevue for settings/changes. b/s coarse w/diffuse crackles and occ exp wh. sxn thk tan secretions. mdi given x3. plan: cont w/mech support.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-21 00:00:00.000", "description": "Report", "row_id": 1559412, "text": "MICU/SICU NPN HD #8\nS/O:\n\nNeuro: pt remains sedated with fentanyl/midazolam and paralyzed with cisatracurium, drips titrated to sedation/paralysis.\n\nResp: pt received in prone position, pt for a total of 11 hrs, pt remains intubated on AC 34x350x0.70/+14, PEEP increased this PM after recruitment, post-ABG 7.20/79/78, SpO2 87-95, LS are coarse all fields, suctioned q2-3h for minimal amts thick tan secretions\n\nCV: HR 89-127 SR/ST without notable ectopy, BP 106-141/55-80, please see flowsheet, tachycardia resolved with supination\n\nSkin: 5cm x5cm eccymotic area over LUQ outlined, skin tear over sacrum dressed with Duoderm\n\nGI/GU: abd obese, soft, NT/ND, BS present, Peptamen resumed at trophic rate of 10cc/h, pt has has 3 large loose green stools this PM, Foley replaced this PM, Foley has patent for clear yellow urine in adequate amts\n\nLines: left SC TLCL day #8, right radial art line day #8\n\nID: T-max 102.2 PR, pan cultured.\n\nSocial: multiple family members in to visit today including pt's father.\n\nA:\n\naltered breathing r/t acute inflammatory process\nhigh risk for infection r/t invasive lines, ETT, indwelling cathether\n\n\nP:\n\ncontniue to monitory hemodynamic/respiratory status, continue abx as ordered and follow micro data,continue nutritional support as reccomended, social service c/s for husband\n" }, { "category": "Nursing/other", "chartdate": "2167-02-21 00:00:00.000", "description": "Report", "row_id": 1559413, "text": "Pt remains on full vent support. Attempted recruitment maneuver with an increase peep to 14. Pao2 increased on 8 torr. ABG continues with a respiratory acidosis. BS coarse with minimal secretions\n" }, { "category": "Nursing/other", "chartdate": "2167-02-22 00:00:00.000", "description": "Report", "row_id": 1559414, "text": "pt.remains on ac ventilation, mdi albuterol/atrovent given q4h, bs coarse/diminished, abg acidotic, continues to have increased pips, sats in low 90's, no changes made, will remain as is, sx for white to clear secretion.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-22 00:00:00.000", "description": "Report", "row_id": 1559415, "text": "NPN SHIFT 1900-0700:\nNEURO: Pt remains sedated and paralyzed. Pt over breathing vent; discoordinated abd resp, desaturated to 90-92%. Titrated gtt as needed with good effect. Fentanyl 500mcq/hr, Versed 20mg/hr, Nimbex 0.30mg/kg/hr. Train of 4 switched to R face where more visible, results: w/ 7ma of energy. R pupil 3 w/ sluggish response. L size 3 w/ brisk response. +corneals. Unresponsive, no mobility.\n\nRESP: Intubated, AC/14/.70/350/14. B/L BS present, coarse w/ rales bibasilar. 0300 desaturated 90-92%. Increased NMB; sats increased to 96%. ABG=7.22/73/63/0/31/92%. Pt w/ resp acidemia and hypoxemia. HO aware. RT to do recruitment this AM.\n\nCV: NSR, no ectopy. QRS-0.08 PR=0.20 QT=0.38. Anasarcic. All peripheral pulses present. AM K=3.9, Mg-1.9. No repletion since TPN w/ electrolytes. No weight change. Pt positive for shift.\n\nGI: Abd distended, soft. Pt w/ OGT and peditube. Placement confirmed. Patent. No residuals. Peptimen via peditube at 10cc/hr, not to bre advanced. BUQ w/ no audibel BS. BLQ w/ hypoactive BS. +large liquid , green, guiac neg. Unable to obtain specimen, mushroom cath not effective. Rectal bag applied.\n\nGU: Foley C/D/I. Bladder pressure =16. No urinary retention. Good output. BUN/Cr 20/0.5. Yellow/clr.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-26 00:00:00.000", "description": "Report", "row_id": 1559432, "text": "Respiratory Care Note\nAddendum: Based on Sao2 of 100%, and PaO2 78, Fio2 decreased to 60%.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-26 00:00:00.000", "description": "Report", "row_id": 1559433, "text": "Respiratory Care Note\n\nPt remains intubated and fully ventilated on AC settings following ARDS Net Protocol. Pt transported to CT Scan uneventfully. Remains paralyzed and sedated. Increased FiO2 to 80% after return from CT Scan due to desaturation. Able to titrate down to 70% during the noc. Will continue to wean FiO2 if tolerated. MDI's given per order. ETT secure. Pt remains tachycardic.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2167-02-26 00:00:00.000", "description": "Report", "row_id": 1559434, "text": "Nursing Progress Note:\n\nPlease see Carevue and MARs for further details of pt's care.\n\nNEURO: PEARL, sluggish, 3mm bilaterally. Pt on maximum dosage per pharmacy of Nimbex at 10mcg/kg/min. Fentanyl at 500mcg/hr. Versed at 22mg/hr. TOF on 6 amps, ICU team aware of this.\n\nCV: HR has been 113-145, ST no ectopy. HR now in the 1-teens, lower than earlier today. SBP has been 100-150. Tmax 100.6, tylenol given with effect. CVP has been 19-24, team aware of this as well.\n\nRESP: Pt remains on A/c at 60%, rate=36, PEEP=22, TV 350. Lung sounds coarse vilaterally. Suctioning minimal secretions. ABG this am showing acidosis, another gas just sent this evening, results not back yet.\n\nGI/GU: BS hypoactive, TF at goal of 55/hr. Rectal bag removed, no diarrhea this afternoon. distended, soft. Foley to gravity with good UO. Urine , clear.\n\nSOCIAL: Family meeting planned tomorrow evening around 5pm with Dr. . Husband aware of this. Social worker and bank rep aware as well and all plan to attend. Social worker and rep both need to be contact tomorrow to be told of time of meeting. Lots of family at bedside, resident and nurse updating them on patient's condition.\n\nSKIN: Stage 1 pressure sore on coccyx, new duoderm applied.No other breakdown at this time.\n\nENDO: Pt remains on insulin gtt, titrating per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-26 00:00:00.000", "description": "Report", "row_id": 1559435, "text": "Nursing Progress Note:\nNimbex running at max of .3mg/kg/hr per ICU guidelines.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-27 00:00:00.000", "description": "Report", "row_id": 1559436, "text": "NPN; SHIFT 1900-0700:\n\nNEURO: Pt sedated on Fentanyl and Versed. Pt displaying hypertension and tachycardia w/ mod manual manipulations at start of shift. Titrated Fentanyl to 600mcq/hr as per HO, versed titrated w/ good effect. Paralyzed on Cisatracureum max at 0.3mg/kg/hr. Train of 4, on 7ma of energy. Pt displaying no s/s of discoordinate breathing. Pt w/ no spon nor purposefull mobility, unresponsive to noxious stimulus. +PERRLA, 3mm, sluggish. +corneals.\n\nRESP: OETT, 7fr, 22 at lip. AC/36/.60/350/22. 1800 ABG 7.34/61/86/4/34. Sat 95-97% B/L BS diminished, coarse, w/ exp. wheezing and rales throughout. Suctioned Q4hr, small amt of yellow, mod thick secretions.0000: Pt desatted to 86% PIP unchanged in the 50's. TV WNL. Computers down, called lab, PO2=52 PCO2=68. Pt hypoxemic, more hypercapneic. HO aware. Increased FIO2 to 80 as per HO w/ good effect. Pt satting 94-98% 0200 ABG: 7.33/66/83/5/36.\n\nCV: 0000: Pt in sinus tachycardia, 130's, hypertensive, ABP 180's/90's unrelated to any manual manipulations. Afebrile. Checked for urinary retention. O2 sat 86%, suctioned and yielded min secretions. Titrated gtt w/o effect. HO aware. 12- lead ECG WNL. Lopressor 2.5mg IV given w/ good effect. HR 100-110, ABP 120-130/60-80. Pt more anasarcic. Skin pink, warm. All peripheral pulses present w/ doppler. CVP=20 sec to RVF displayed on echo. HCT/Hgb WNL= 33.1/8.4. K+=4.4. Mg+=1.8, mag oxide 800mg given.\n\nGI: Abd distended, soft. Hypoactive BS auscultated. TF at target via post-pyloric pedi-tube. Residuals . OGT w/ minimal gastric secretions, . Gastric secretions milky in appearance, HO aware. Aspiration precautions in effect. No BM. On standing bowel regimen. TPN d/c'd. Insulin gtt titrated as protocol.\n\nGU: Foley C/D/I, patent. No bladder residuals. Urine sec to rifampin, clear. BUN/Cr= 21/0.4. Unable to weigh pt sec to bed malfunction. Pt positive 3L for shift sec to add'l IV abx.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-27 00:00:00.000", "description": "Report", "row_id": 1559437, "text": "REspiratory Care Note\n\nPt remains intubated and fully ventilated on AC settings. I/E remains 1:1 to assist in oxygenation. PaO2 earlier in shift was 52 so FiO2 increased to 80% with good effect. PIP's and plateau pressures slightly higher this shift. BLBS are coarse. Sxn for yellow sputum. Albuterol and Atrovent MDI's given per order with no effect in PIP's.\nABG shows adequate oxygenation on 80%.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2167-02-27 00:00:00.000", "description": "Report", "row_id": 1559438, "text": "NPN SHIFT 1900-0700 ADDENDUM:\n\nGI: +BM, large, soft, brown, guiac neg. Specimen sent as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-27 00:00:00.000", "description": "Report", "row_id": 1559439, "text": "Respiratory Care Note\nPt remains on a/c settings see carevue. Weaned fio2 to 70 from 80.\nPip remain 48-50. B.S. sl. improved areation by end of shift with decreased rales. Tube retaped this shift, family meeting this evening.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-14 00:00:00.000", "description": "Report", "row_id": 1559380, "text": "MICU/SICU NPN HD #1\nBriefly this is a 32 yo F transferred from OSH last PM after a seven day admission to the ICU for polysubstance ingestion overdose for which pt was intubated after vomiting and aspirating. PMH significant for bipolar d/o, depression, multiple suicide attempts, ventral hernia repair, thymectomy (thyoma), GERD and polysubstance abuse. Pt transferred to for further management of failure to wean from mechanical ventilation and possible ARDS.\n\nROS:\n\nNeuro: pt is sedated with midazolam, pt will attempt to open eyes when asked, inconsistently following simple commands, PERRL/sluggish/4mm\n\nResp: intubated with #7 ETT, 22cm at the lip, day #8, on AC 20x500x0.60/+10, last ABG 7.35/37/83, SpO2 95-97%, LS coarse all fields, suctioned x3 for scant thick tan secretions, copious oral secretions\n\nCV: HR 94-103 SR/ST without ectopy, BP 97-114/62-73, CVP 5-17, please see flowsheet for data\n\nSkin: pt has multiple eccymoses over abdomen and arms likely from needle sticks, perineam and peri-rectal area are red\n\nGI/GU: abd is soft, NT/ND, hypoactive BS, NGT in left nare to LIWS draining small amts green bilious fluid, NPO, Foley patent for clear concentrated urine in adequate amts\n\nLines: left SC TLCL day #2, right radial art line day #1\n\nID: afebrile overninght on Imipenem, ceftriaxone and clindamycin, numerous cultures pending at Caritas/GSH\n\nFEN: NS at 150cc/h infusing, K+ repleated with 60 mEq KCl, free Ca2+ 1.22 this AM, TPN infusing\n\nSocial: pt is married, no children, full code\n\nPlan: continue to monitor hemodynamic/respiratory status, lung protective ventilation, contniue abx as ordered, contniue to monitor lytes and replete PRN, closely monitor fluid balance, continue TPN\n" }, { "category": "Nursing/other", "chartdate": "2167-02-14 00:00:00.000", "description": "Report", "row_id": 1559381, "text": "Resp: pt intubated from osh. EET #7 taped and secured 22@lip and placed on a/c 10/500/+8/60%. BS auscultated reveal bilateral coarse sounds. Suctioned for moderate amounts of charcoal tinged secretions. MDI's administered Q 4 combivent with no adverse reactions. Vent changes to decrease TV to 450/^ peep to 10. AM ABG's 7.35/37/83/21. No RSBI. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-15 00:00:00.000", "description": "Report", "row_id": 1559388, "text": "pmicu nursing progress note\nresp: this morning pt having asynchronous breathing, prolonged expiratory phase---fentanyl boluses and increased the drip to 450mcg/hr and the versed drip infusing at 10mg/hr. present vent settings are ac 60% tv 350 x 30 vented breathes and 10 peep, with o2 sats of 95-96%, and an abg of 113 52 7.28. at 1:20p pt placed on pressure control(failed) 60% x 30 vented breathes 10 peep 30 insp press and tvs of 580-617, with an abg of 106 57 7.23. bagged, lavaged and suctioned for a small amt of thick white sputum (sent for gram stain and culture). lung sounds are coarse and deminished at the bases. cxr done. ??esophageal balloon placed tomorrow. receiving combivent treatments.\n\ncardiac: bp 97-110/50-58 with a pulse of 90-100 sr/st, with no ectopy noted. cvp 9-14 (would like to keep cvp around 12). iv of ns changed to lactated ringers at 150cc/hr. + pedal pulses, feet warm to touch. several liters positive.\n\nid: FEBRILE temp 101.7 ax, 102.5 ax and 102.5ax. rec'd tylenol at 11:30a and at 4p. dc'd clinda and ceftriaxone--continues on imipenim. wbc 3.28. one set of blood cultures, urine and sputum cultures sent. cooling blanket on. receiving afrin for ??sinusitis.\n\ngi: abdomin soft/distended. unable to hear bowel sounds. og tube in place-on low interm suction. bilious material obtained, ph 5 and ob neg. tpn infusing at approx 42cc/hr. resp status too unstable to go to abdominal c-scan. elevated amylase, tricyclerides and lipase.\n\ngu: foley bag changed. bun 23 and creat .6. urinary output is approx 60-80cc/hr.\n\nendo: please see carevue for all previous fingersticks--presently pt is on 1u/hr of reg insulin with a fingerstick of 86.\n\nheme: hct at 4a was 31.3 and at 5p 31.4.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-16 00:00:00.000", "description": "Report", "row_id": 1559389, "text": "Resp: pt on a/c 30/350/10+/60%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear apecies with diminished bases. LS ^ aeration noted. MDI's administered Q4 hrs combivent. AM ABG's 7.30/52/116/27, no RSBI performed. No changes noc, possible CT today. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-16 00:00:00.000", "description": "Report", "row_id": 1559390, "text": "O. Neuro pt sedated fentanyl 450meq and versed 10mg iv q hr pupils pinpoint no movement\nresp on 60%/350/30/10 abg 7.30/52/116/- lungs coarse to clear o2 sat 98% sx min amt of sputum\ncardiac HR 88-94 nsr without ectopy bp 97/49-108/52 mag 1.7 tx 2gm repeat 2.1 K+ 4.1 Hct 29.8, cvp 10-14 IVF 10-140cc LR to keep cvp >12 INR 1.3 skin warm diaph pp+3\ngi abd soft distended bs+ ogt output bilious 200cc no stool amylase 264\nEndo insulin 1u reg q hr bs 100-135\nID temp max 102.7 cont on imipenem cooling blanket on tylenol supp q 4hr wbc 7.7\nGU u/o > 80cc yellow cloudy bun 15 cr .7\naccess mult LSC, Aline Rt R\na. fever, asp pnx\npancreatitis\nsuicidal attempt\np. monitor temp await cx results, cooling blanket prn, tylenol per rectum not to exceed 4gm qd, antibx as ordered, obtain stool sample\nsedate as needed to improve resp and gas exchange, monitor for s+s of withdrawal\nnpo ogt to lis feed TPN monitor bs keep bld sugars 80-120\nsupport family as needed\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-19 00:00:00.000", "description": "Report", "row_id": 1559405, "text": "Respiratory Care:\nPt continues on mechanical ventilation via ETT. No changes made to ventilator settings throughout day; please see Carevue for details & corresponding ABG's. BS=wheezy rhonchi scattered t/o with some relief after suctioning & MDI's. MDI'sx3 given as ordered. Plan to continue ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-23 00:00:00.000", "description": "Report", "row_id": 1559420, "text": "MICU/SICU NPN HD #10\nS/O:\n\nNeuro: pt remains sedated with fentanyl/midazolam and paralyzed with cisatracurium, PNS with 7mA on right face\n\nResp: pt remains intubated on AC 36x350x0.8/+20, PEEP increased this PM after unsuccessful recruitment, transpulmonary pressures and lung compliance measeured at bedside today, PEEP increased as indicated, a trial of APRV was attempted unsuccessfully as pt desaturated, LS are coarse, SpO2 88-93%, last ABG pending\n\nCV: HR 91-107 SR/ST without notable ectopy, BP 93-134/51-66, CVP 13-17, please see flowsheet for data\n\nSkin: rash on face and trunk, skin tear over sacrum dressed with Duoderm, 5cm x 5cm area of eccymosis over LUQ\n\nGI/GU: abd obese, soft, BS present, Peptamen VHP infusing at goal rate of 20cc/hr, Foley patent for clear yellow urine in adequate amts\n\nLines: right radial art line day #10, left SC TLCL day #10\n\nID: T-max 99.5 on Vanco, Levo & Zosyn\n\nSocial: family meeting today to update family on pt's condition and plan\n\nA:\n\naltered breathing r/t acute inflammatory process\nhigh risk for infection r/t invasive lines, ETT, indewlling catheter\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contniue abx as ordered and follow micro data, provide emotional support to family\n" }, { "category": "Nursing/other", "chartdate": "2167-02-24 00:00:00.000", "description": "Report", "row_id": 1559421, "text": "Respiratory Care\nPt remains intubated and ventilated on a/c 350 x 36 80% 20 peep. No remarkable changes overnight. Breath sounds are decreased with scattered expir. wheezes. Given Albuterol/atovent inhalers as ordered. Airway pressures remain high- Pip 50-55/Pplat44-47; no measured autopeep.. ABGs-adequate oxygenation with resp acidosis.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-24 00:00:00.000", "description": "Report", "row_id": 1559422, "text": "NPN: SHIFT 1900-0700:\n\nNEURO: Pt adequately sedated and paralyzed. Fentanyl 500mcq/hr, Versed 20mg/hr. On max Nimbex at 0.3mg/kg/hr. Though train of is four w/ 7ma of energy, pt is adequately paralyzed displaying no s/s of discoordinate breathing patterns. B/L pupils 3-4mm, round. R sluggish, L brisk. + corneals. No spon nor purposeful movement w/ noxious stimuli.\n\nResp: OETT #7, changed position and ties, remains 22 at lip. AC/36/.80/350/20 I:E= 1:1. B/L BS coarse w/rales and E wheezing throughout. Suctioned Q4hr w/ small amts of yellow, mod-thick secretions. Esophageal balloon intact. PIP remain high at 50-55. Pplateau in 40's. Pt w/ periods of desaturation to upper 80's, low 90's accompanied w/ tachycardia and 20-30 pt rise in BP. No visible s/s of distress noted. Ho aware. No interventions ordered. AM ABG: 7.30/68/83/4/35. Pt remains hypercapneic with improved oxygenation, though P/F= 1:1.\n\nCV: NSR-ST. No ectopy. QRS= 0.08 PR=0.20 QT= 0.40. BP WNL. Anasarcic. All peripheral pulses present. Skin pale, warm. AM K+=4.3, Mg+=2.0. HCT 25.6, WNL. Pt euvolemic for shift, +70.2.\n\nGI: Abd distended, soft. Hyppoactive BS BLQ. Large amt of loose, green , guiac neg. On peptamen TF at 20cc/hr via peditube, not to be advanced as per HO. Aspiration precautions. TPN at target. Insulin gtt titrated to keep BS 80-100. GTT's changed from D5W to NS w/ good effect. OGT w/ minimal gastric secretions, green, bilious.\n\nGU: Foley C/D/I. Bladder pressure WNL, 15. Urine yello, clear, good amts.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-20 00:00:00.000", "description": "Report", "row_id": 1559406, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Pt remains adequately sedated on Versed 20mg/hr, Fentanyl 500mcg/hr and paralyzed on Cisatraneum 0.125mcq/kg/min. Sedated to . Unresponsive to noxious stimulus. Train of 4 to R eye lid, w/ 5ma of energy. +PERRLA, 3mm brisk. +corneals. Weak cough w/ suction. No gag.\n\nRESP: Pt intubated on AC/34/.60/350/10. PEEP increased to 12 as per covering attending and Dr. during rounds at 2100. PIP unchanged at 44-47. Compliance 15. B/L BS present, coarse w/ rales. Scant secretions. No s/s of resp distress throughout shift. 0300 ABG= 7.27/70/99/2/34. PO2 improved from 88. Other values remain unchanged. Pt remains hypercarbic at 70. Esophageal balloon intact.\n\nCV/Metabolic: Pt in sinus tachycardia, rate 102-108 secondary to low grade temp; Tmax 100.4. No ectopy. QRS 0.8 PR 0.20 QT=0.38. This AM, afebrile at 99.4. In NSR 89-95. No s/s of cardiac distress. +anasarca, third spacing, non-pitting edema. Skin warm, pale. Multi ecchymotic areas since admission, no progression. PT/PTT WNL. AM HCT stable at 23.6, previous 24. WBC 4.8, previous 5. On insulin gtt, titrated for 80-100 goal. BS= 96-146. Currently at 17u/hr. K+=4.6, up from 4.2. Mg+=1.9. No repletion, TPN w/ k+,Mg+. Will inform HO.\n\nGI: Abd distended, soft. No audible BS. No BM. On reglan, lactulose, and colace ATC. TPN at target. OGT w/ 300cc bilious, green drainage for shift.\n\nGU: Foley C/D/I. No urinary retention. Bladder pressure checked Q4hr, ranged 13-16. Clear/Yellow. BUN 15, Cr 0.6. Pt +16kg since admission. I/O +987 for shift.\n\nSKIN: Rash to upper, anterior torso unchanged, papular, reddened, generalized. Hydrocortisone applied as ordered. Back rash worsened, macular, reddened, generalized throughout back. Groin, axilla, posterior abd, groin rash resolving, pink, macular. Rectal rash excoriated, sacral abrasion progressed to stage II, pink, no drain. T/P, pillow wedges used. Kept clean/dry. Barrior ointment w/ anti-fungal applied. Special bed w/ low air loss mattress will be ordered. Will recommend Dermatology consult.\n\nVANCO TROUGH=30.8\n" }, { "category": "Nursing/other", "chartdate": "2167-02-20 00:00:00.000", "description": "Report", "row_id": 1559407, "text": "Resp Care,\nPt. remains intubated on A/C 350/34/.6/12 peep. Peep increased to 12 this shift. ABG 7,27/70/99/34. PIP 44/ Plateau 38. Episode of PIP 50 this am after being turned. Sedated and paralized. Maintain current vent settings. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-20 00:00:00.000", "description": "Report", "row_id": 1559408, "text": "Resp Care\n\nPt remains on full vent support of A/C 350/34/60%/12. PiP's in the low 50's with a plateau of mid 40's. BS remain coarse with small amts of sputum. Plan is to keep on current settings.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-20 00:00:00.000", "description": "Report", "row_id": 1559409, "text": "MSICU NPN 0700-1900\n\nSedated and paralyzed. Cisatracurium increased to .13 d/t resp mvmt with improvement. Versed and Fentanyl both weaned 20% as they were initially increased to higher dose in attempt to decrease spont mvmt. Tol well so far, no tachycardia or HTN noted. BP stable off Neo gtt.\n\nNo vent changes. Sm amt thin white sputum, sent for c/s g/s. Initially had inc resp mvmt after suctioning. Improved since increase of Cisat. PIPs ~50. Placed on Triadyne bed. Currently tol turning 15 degrees q 30min. ETT rotated.\n\nRemains on TPN without Lipids. Started on Peptamin at 10cc/hr. Plan to monitor residuals overnight. Max residuals after 3hrs = 30cc. Rate to stay at 10cc MD. . No bowel sounds noted.\n\nStill with facial and back rash. No change. Dime size skin tear noted on coccyx. Pink base, scant serous drainage. Noted foot drop and external rotation bilaterally. Multi podus boot ordered.\n\nAfebrile. Vanco peak pnd.\n\nHusband called and updated. No visitors as yet.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-21 00:00:00.000", "description": "Report", "row_id": 1559410, "text": "pt.remains on ac ventilation, proned on nocs, no real improvement, bs coarse, mdi alb/atro given q4h, abg acidotic, will probably remain as is.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-21 00:00:00.000", "description": "Report", "row_id": 1559411, "text": "NPN (NOC): PT REMAINS INTUBATED. OVER THE COURSE OF THE EVENING, HER SATS DROPPED FROM 97-90, SO PT ~ 2AM. INITIALLY, SHE ONLY GOT WORSE W/ SATS AS LOW AS 87%, HOWEVER, OVER THE COURSE OF THE NEXT FEW HRS THEY HAVE COME UP TO 91%. CURRENT VENT SETTINGS: A/C 34X350X70% + 12 PEEP. PIP'S REMAIN ~ 50. SEDATION AND NMB TITRATED UP (SEE FLOW SHEET) AND SHE IS NOT MOVING BUT HR AND BP UP TO 120'S AND 134/71. BS'S COURSE, BUT ONLY SX'D FRO SM AMTS OF WHITE FROTHY SECRETIONS. TMAX 100.9. TF OFF WHEN . INSULIN DRIP TITRATED PER FLOW SHEET TO KEEP FSBS IN 80-100 RANGE. UO ADEQUATE, BUT SHE IS RUNNING + ON I&O'S AND IS EDEMATOUS. ALSO, HCT LOWER THIS AM, DR. AWARE- NO ORDERS TO TRANSFUSE. MOTHER CALLED, SHE HAS BEEN MADE AWARE THAT THE PT IS GETTING WORSE.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 1559430, "text": "Addendum to NPN\nFamily meeting this PM to discuss pt's condition and progress as well as plan of care. Dr. informed the family that in current condition cardiopulmonary rescuitation would likely not be effective in a cardiopulmonary arrest and therefore it is not indicated. Pt is now DNR. Additionally, based on pt's new onset tachycardia and hypertension, a CTA will be obtained to r/o PE.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-24 00:00:00.000", "description": "Report", "row_id": 1559423, "text": "See progress note in chart.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-26 00:00:00.000", "description": "Report", "row_id": 1559431, "text": "NPN 1900-0700\nGeneral: Pt cont. on paralytic, .30mg/kg/hr, unresponsive, TOF on 6ma of energy. Was taken to CT angio of Chest at , tolerated procedure well. 2200: T=102.3 HR 136-138, given 1gm Tylenol per NGT as ordered per HO, BC X2, Fungal Cx, Urine with reflex sent, still need sputum cx unable to obtain. Temps went down to 101.3 for a couple of hrs =102.3 HR 138-140, given 1gm tylenol at 0240, cooling blanket applied with ice packs to bilat groina and axilla, current T=101.3, HR 131-134. Flagyl IV started. Please check morning labs and ABG's.\n\nCode Status: DNR/DNI, CPR not indicated\n\nNeuro: Pt unresponsive, sedated on midazolam 22 mg/hr, fentanyl 500mcg/hr, and , x 2, pupils 3mm/3mm sluggish, SR up x 4, bed in rotating mode.\n\nCV: HR 131-140 ST no ectopy, SBP 128-138/ 84-87, Adjusted CVP 6-7, general anasarca, 3+ Pedal Pulses Palpable bilat, compression stockings intact.\n\nResp: Lungs Coarse throughout, Sx x 1 with trace amt of whitish colored sputum, unable to obtain cx. CMV FIO2 70%, RR 36, PEEP 22, TV 350, PEAK 45-50, SPO2 90-94%.\n\nGI: Abd softly distended, hypoactive BS X 4 quad, green liquid draining from rectal bag, Peptamen VHp infusing at 40cc hr with goal of 55cc/hr.\n\nGU: Foley cath intact, patent, draining urine in adequate amt. see careview.\n\nSkin: Bed on Rotating mode, skin redenned with dependent edema, duoderm to coccyx intact, Abd LUQ appears less eccymotic today, no visible rash to face.\n\nSocial: Family in to see pt last night, husband understanding of Plan of Care and code status.\n\nPlan of Care: Check am labs and ABG's, cont to monitor sats, assess temp and tx with prn meds, notify MD of T >102.3, adm abx as ordered, continue to provide emotional support to family.\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-15 00:00:00.000", "description": "Report", "row_id": 1559384, "text": "NPN\n7 PM - 7 AM\nMSICU\nASP PNA/ARDS\nS ORALLY INTUBATED AND SEDATED\nO PL SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nRECIEVED PATIENT MECH VENTILATED ON AC MODE RATE OF 20..FI02 OF 50 % ..10 PEEP.TV 450...PT COMPLETELY VENT VENT SUPPORT ....VERSED AT 20 MG/HR ..RATE ^ TO 40 MG/HR ..WITH FREQUENT 10-20 MG BLUSES ...ABG PO2 IN THE LOW 70'S..PH 7.34 RANGE ..CO2 38-44..BICARB NL...MANY VENT CHANGES MADE ..CURRENTLY ON TV OF 350..FI02 ^ TO 60%..RATE INCREASED TO 30..WITH PT CONTINUED WITH VENT SUPPORT ..PIP 21-34..SPONT TV 450 ..SUCTIONED TIMES ONE FOR SMALL AMOUNT OF WHITE SXNS ..LUNGS COARSE AND DIMINSHED AT THE BASES ..SECOND SEDATION BEGUN AT MN..FENTANYL STARTED AT 100 MCGS/HR ..WITHOUT AFFECT ..PARALYZING DEFERED BY TEAM ...\nCV HR 90'S..SR ..K 3.3 REPLETED WITH 60 MEQ KCL IV ..REPEAT K 4.2..SBP BY RIGHT RADIAL ALINE 90-110'S/50-60'S..CVP 3-4 RANGE WITH GOAL ..NS BOLUS OF 500 CC GIVEN ..IVF CONTINUE AT 200 CC/HR ..4.5 LITERS POS AT MN..\nGU URINE OUTPUT 60-80 CCQ1..BUN/CREAT 23.6...\nGI OGT TO LOW INTER SXN..OUTPUT 200 CC GRN BILIOUS ..OB + ..PH 5 ..BOWEL SOUNDS HYPOACTIVE ..NO STOOL..CLAMPED AT 0600 FORR TYLENOL..\nID T MAX 101.4..CX'D ON ..ALL CXS PNDG..TYLENOL RTC ..WBC 6..CONTINUES ON ABXS ..\nENDOCRINE ..INSULIN AT .5 U/HR WITH FINGER STICK RANGE 100-134..INFUSION INCREASED TO 3 U/HR WITH GOAL OF ACCEPTABLE RANGE OF 80-100..\nLFT WITH 617..LDH 428...\nNEURO PUPILS 2 BILAT BRISKLY REACTIVE TO LIGHT ..FACIAL GRIMACE TO SUCTIONING/MOUTH CARE ..\nA POOR RESP RESERVE IN SETTING OF ARDS\nP RECONSIDER PARALYZING \nABD CT SCAN\nCHECK ALL CXS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-15 00:00:00.000", "description": "Report", "row_id": 1559385, "text": "Respiratory Care:\nPt. extubated to a 50% cool neb. RR = ^^., O2 Sat. 98% BP = 93/40.\n will watch for a while and consider NPPV if necessary.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-15 00:00:00.000", "description": "Report", "row_id": 1559386, "text": "Respiratory Care:Please DISREGUARD the prior note by me. It is on the wrong patient. So Sorry...\n" }, { "category": "Nursing/other", "chartdate": "2167-02-15 00:00:00.000", "description": "Report", "row_id": 1559387, "text": "Respiratory Care:\nPt remains back on CMV after multiple changes and short trials during rounds today.\nShe ended up where we started without paralytics as yet. Remains acidotic, and I've problems with the RR shown on the vent and her actual RR that is substantially less. Dont't know why but have my theory about what is happening.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-18 00:00:00.000", "description": "Report", "row_id": 1559398, "text": "NPN Addendum\n\nPt SBP dropped to 70's-80's x approx 10 minutes around 0600-Dr. notified; SBP presently 88-93-will start Neo gtt if needed MD; only 20cc urine out this hour after lasix dose-MD aware; will cont to monitor and implement POC.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-18 00:00:00.000", "description": "Report", "row_id": 1559399, "text": "Respiratory Care:\nPt dyssynchronous with vent this am; sedation increased with little change. Pt eventually paralyzed & settings changed to A/C with good results. Esophogeal balloon study completed; able to increase peep & pip if needed. Suctioned for sm amts of wht sputum throughout day; MDI x 3 given; little change in BS continuing with coarseness throughout. Plan to continue ventilating as ordered. Please see CAREVUE for details in vent changes & subsequent ABG's.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-18 00:00:00.000", "description": "Report", "row_id": 1559400, "text": "NPN\n\nDifficult day, acidotic, required paralytics.\n\nNeuro: She is presently well sedated on 500mcg of fent and 20 mg of versed an hour. Her pupils are equal 3mm, and briskly reactive to light. She given numerous boluses this morning for overbreathing the vent by 20-40 for a total rate of 50-70, she was given boluses as high as 500mcg with a very brief effect. After her stomack was emptied of 450cc of bilious material and her bladder of 900cc of urine she was much more comfortable though still required paralysis in order to ventilate her. Train of four was done, her eye lid was chosen because it required less enegry to cause a twitch. Her baseline is 5. Increasing her cisatracurium in 25% increments to a total of .1mg/kg/hr did not change her train of four but pe the esophageal balloon pressures indicate that she is not making any efforts to breath.\n\nCV: VSS, BP 100-115/40-50s, HR was in the 90s-1teens but after her postgastric tube and foley were drained her HR decreased to the 70s. I was able to turn her neo off fairly early in the morning.\n\nResp: She remains vented. Difficult to ventilate this morning, LS have very coarse rales throughout, minimal secreations. After her G tube was emptied of 450cc bilious material her rate went from the 50s-70s to 30. She stayed there for about an hour and then her rate again climbed and she had a worsening resp acidosis. She was paralysed, her foley was clotted off, after this it drained of 900cc of urine. Presently on AC (changed from PCV) 350x34, 10 PEEP, of auto PEEP, 50%, her ABG on the was 7.25/64/117. Her peak pressures are 47-49, her esophageal balloon presures showed that she could tolerate going up on her plateau presures by 5 - this has not been done.\n\nGI: As above, emptied out 450cc of OB pos bilious material, she also had a liquid, green, OB pos BM. Her TF remain on hold due to her high residuals, she conts on TPN. Her ABD is obese, soft, hypoactive BS.\nAfter her foley was emptied her bladder pressure was 11.\n\nGU: Her foley was clotted, her urine had some sediment and was sent for culture.\n\nEndo: Conts to require insulin, she is presently at 11 units/hr.\n\nID: She has been basically afebrile today, her abx were changed.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-19 00:00:00.000", "description": "Report", "row_id": 1559401, "text": "NPN SHIFT 1900-0700:\n\nNEURO: Pt sedated on Fentanyl 500mcg/hr, Versed 30mg/hr, paralyzed on Cisatracurium at 0.1mcq/kg/min at start of shift. Train of 4 to R lid Q2hr done; results w/ 5mamp of energy. Sedated to 2, 6. Weaned Fentanyl to 300mcq/hr, Versed 10mg/hr, and Cisatracurium to 0.05mcq/kg/min as per HO. Tol well displaying no s/s of distress. +PERRLA, 3mm Brisk. Unresponsive to noxious stimulus. No movement. No gag. Weak cough during suctioning. 0415: Increased sedation secondary to bronchospastic event. Bolused Cisatracurium 0.05mcq, increased gtt to 0.1mcq/kg/min as per Dr. . Train of 4; w/5. Titrated sedation to Fentanyl 400mcg/hr, Versed 10mg/hr this AM. Tol well, no s/s of distress.\n\nRESP: Pt remains intubated on AC 34/50%/350/10. 2100 ABG: 7.27/59/79/0/28/97%. Pt remains hypercarbic, though much improved. O2 sat=98%. Scant to no secretions, suctioned Q4hrs. PIP=40's. No distress, no spon resp throughout night. B/L BS present, coarse w/ rales throughout. 0300 ABG= 7.28/61/66/0/30/92%. Increased FIO2 to 60%. 0415: RESP DISTRESS post suctioning. TV=100-200's. RR=40's. O2 sat=92%. S/S of bronchospasms. PIP=50-60's. Dr. at bedside. Titrated sedation and paralytic as stated above. Bronchodilator MDI given. Episode resolved by 0430. ABG sent 0430= 7.25/71/74/0/33/96% ABG to be redrawn at 0600.\n\nCV: NSR, no ectopy. Inverted P and T waved. PR=0.20 QRS=0.08 QT=0.38. MAP 55-62. CVP=14-15. Weight +13 kg, I&O +987 for shift. Pt anasarcic. Started Phenylephrine at 0.10mcq/kg/min and titrated to off by morning. Weaned sedation to improve UO WNL throughout. DP via doppler. All other pulses palpable. Skin cool, pale. HCT down from 27.1 to 24 this AM. DR. aware, no interventions till rounds w/ team. UO WNL throughout. CVP 12 this AM, MAP>60 off neo. No s/s of bleeding. OGT drain bilious, green.\n\nGI: Abd distended, soft. No audible BS X4. HO aware. On reglan. OGT and ped. tube clamped. OGT w/ tot 150cc for shift. No TF. TPN at target. No BM.\n\nGU: Foley C/D/I, patent. No drainage noted. Flushed X1. Good UO. Yellow, clear. BUN/Cr, 19/0.5.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-19 00:00:00.000", "description": "Report", "row_id": 1559402, "text": "RESP CARE: Pt recieved on AC 350/34/.50/10PEEP.Lungs bilat crackles R>L, coarse throughout. MDIs given Q4. At 0400 post deep sxing, pt became tachypneic with RR 42,air trapping/ dysynchronous with vent. Pt given 20 P albuterol, sedation/paralytic increased with good effect.PLAN: Continue supportive care\n" }, { "category": "Nursing/other", "chartdate": "2167-02-19 00:00:00.000", "description": "Report", "row_id": 1559403, "text": "ADDENDUM NPN SHIFT 1900-0700:\n\nRESP: 0615 ABG unchanged from previous. Pt w/ s/s of bronchospasm. Fentanyl titrated to 500mcg/hr, Versed to 20mg/hr.\n\nGI/Metabolism: Pt remains on insulin gtt titrated throughout shift to BS goal of 80- BS=95 on 13u; Stable on 13U/hr X 4 hrs, BS 90-110. See flowsheet. Afebrile throughout shift, cooling balnket removed.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-19 00:00:00.000", "description": "Report", "row_id": 1559404, "text": "NPN\n\nPt fairly stable today, no changes were made on the vent.\n\nNeuro: She remains sedated and paralysed. Her sedation has stayed the same - fent @ 500mcg/hr and versed @ 20mg/hr. Her paralytic was increase to .125 mg/kg/hr due to accessory muscle use. Her pupils are equal and react brickly to light, she did move her shoulders some when being suctioned this morning. She conts to have some accessory muscle movement but her paralytic was not increased because her ABG was improved.\n\nCV: SBP low 100s to 90s, HR 80s-90s, CVP 12-14\n\nResp: Remains on AC 350x34, 10 PEEP, 60%, last ABG was 7.28/67/87. Her LS are a mix of very coarse rales, wheezes, and rhonchi. Sm amount of sputum to suction, she conts on inhalers. She remains on cisatacurium though she is not paralysed to 2 out of 4 twitches (she twitches ) because her ABG is improved and so there was no reason to increase her paralysis.\n\nGI: Absent BS, no stool, she conts on bowel meds. Her ABD is distended, almost no resuduals from her OGT, her TF remain on hold, she conts on TPN.\n\nGU: She continued to have some urinary retention, her foley was flushed and >300cc came out, her foley was changed to a 3 way which will allow easier bladder pressure readings and flushing if needed. Her urine culture from yesterday is pending.\n\nEndo: She conts on an insulin gtt at 11 units/hr, her BS have been fairly stable - 90s-120s.\n\nSkin: She has an apparent yeast infection in her groin - nystatin powder and antifungal cream is being used. She is now receiving nystatin in her mouth.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-24 00:00:00.000", "description": "Report", "row_id": 1559424, "text": "Respiratory Care\nPt's FI02 being weaned to 70% with Sat's in the low 90's. Suction several times for small-moderate amounts of very thick pale white secreations. Pt's HR increasing to 160 later in the shift, being placed on 100% FI02 until HR declining into to 130's. Weaning FI02 once again. RRT\n" }, { "category": "Nursing/other", "chartdate": "2167-02-24 00:00:00.000", "description": "Report", "row_id": 1559425, "text": "M/SICU Nursing Progress Note 3-7p\n\nNeuro-\nCont to be paralysed and sedated on Cis, Versed and Fentanyl.\nCV-\n1500-Acute ^HR from 110 to 160. EKG>ST. Transiently placed on 100%, lopressor 5mg iv x2> HR 133-142, T=100.3. CVP 17-18 in setting of peep 22= true cvp 7-8. IVF bolus of 250 cc given w/no change in HR. u/o 80-220cc/hr.\nResp-ID\nAC/.70/350/36/peep22. BS course, sputum thin white, speciman sent for T 100.3. Bld cx and urine cx also sent.\nEndo-\nInsulin gtt w/ bs 122-126, no change in rate.\nSocial-\nMany family members visiting w/ pt, beginning to terminate w/ her. Family meeting planned for to update status and make plan. Family aware of grave status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 1559426, "text": "NPN 1900-0700\nGeneral: Pt cont. unresponsive on paralytic Cistatracurium .3mg/kg/hr IV, TOF with 6ma of energy HO aware, midazolam increased to 22mg/hr. At - T=100.8 with HR 138-140, Tylenol 325 per peg given, Bolus 500cc NS given with little effect, 2100- T=101.2 HR 138-140, cold packs applied to R and L groin and bilat. axilla, 650mg Tylenol given per HO with good effect, HR currently down to 110-116 and T=99.8. Pt also changed from Vancomycin IV to Lanezolid IV. (Bld cx., Urine Cx, Sputum cx sent last shift) ABG and am labs drawn at 0430 please check results.\n\nNeuro: Continues on paralytic as noted above,Versed as above, and Fentanyl 500mcg/hr, Unresponsive, PERLA x 2, 3mm/3mm sluggish, does not respond to sternal rub, see TOF above.\n\nCV: HR 110-138, ST no ectopy, BP's 99-114/60-70's, MAP 77-87, Calc. CVP 6-7 (1/2Peep-CVP (17)= Calc CVP), + Anasarca, +3 Pedal Pulses Bilat, Pneumoboots intact bilat.\n\nResp: Lungs Coarse throughout, O2Sat 92-95%, AC .70/350/36/ Peep 22, ET sx x 1 this shift no sputum, Nose sx'd for med amt. of draining clear mucous. O2 sats fell to 91-92% for approx. 1.5hrs after am bath.\n\nGI: BS hypoactive x 4 quad., NGT placement verified by auscultation, Peptamen TF at 20cc/hr goal, HOB 30 degrees, TPN at 44.5cc/hr with Insulin, Rectal bag intact with greenish brown loose draining. OGT intact and clamped.\n\nEndo: FBS 116-123, Insulin gtt at 4u/hr per protocol\n\nGU: 16 Fr. Foley cath intact draining clear yellow urine, > or = 70cc/hr (Foley inserted ).\n\nSkin: Anasarca, skin pale, draining whitish fld from vaginal area, Nystatin suppository given, skin intact, skin care done to anterior and posterior chest, Kinair bed currently on rotating mode, bath given.\n\nSocial: Family in to see pt last night, supportive, ask questions appropriately. Family meeting to take place today to update status and plan of care.\n\nPlan: Check morning ABG and labs, monitor HR and O2sats, obtain FBS and titrate Insulin gtt per protocol, monitor UO, meeting with family.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-17 00:00:00.000", "description": "Report", "row_id": 1559396, "text": "NPN\n\nNeuro: Remains well sedated on 450mcg/hr of fent and 10 mg/hr of versed. Her fent was decreased from 500mcg to 450 mcg, she did require one bolus of 200 mcg for increased RR to the 50s - this had an immediate effect of lowering her RR to the 30s.\n\nCV: BP stable in the 120s/50s, HR 90s-100s - her increased HR appears to be related to the temp spike. CVP was 17 at noon, rales throughout; she was given 20 mg of IV lasix with a good response.\n\nResp: Remains vented on PCV of 40, 10 PEEP, RR 30, FI02 was decreased from 50% to 40%, she over breathes the vent by . Her 02 SATs were in the mid to upper 90s on 50%, they dropped to 91% on 40%. Her LS had crackles throughout, she was 12 liters pos for LOS. Her LR at 100cc/hr was d/ced and she was given 20 mg of IV lasix to which has put out about 900cc of urine.\n\nGI: Conts on her TF, unable to check resuduals due to the small lumen of the tube. She was started on a bowel regiment of docusate, reglan, and lactulose. Her abd is obese, distended, with hypoactive BS.\n\nGU: Given lasix as above, remains quite positive for LOS.\n\nID: Spiked to 101.9, she was cultured, the cooling banket was restarted, and vanco was added.\n\nEndo: Conts on an insulin gtt, the dose has been increased to 12 units an hr, her FS is presently in the 130s. She will have 20 units of insulin in her new bag of TPN - she presently has 10 units in her TPN.\n\nHem: An US was done on her L upper ext because of ? swelling to r/o a clot.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-18 00:00:00.000", "description": "Report", "row_id": 1559397, "text": "NPN\n\nNeuro: remains sedated on Fentanyl 450mcg/hr and Versed 10mg/hr; PERRLA; requiring occasional fent bolus secondary to increased RR with good response.\n\nCV: NSR-ST no ectopy noted; SBP 100's-110's via R rad Aline-good waveform; gen 2+ edema noted; weak bilat pulses; temp up to 101.9 this am-tylenol given, cooling blanket back on; cont. on vanco, imipenem; CVP 13-15.\n\nResp: remains intubated on PCV with insp pressure 30 + PEEP 10 x 30 bpm; Fio2 increased to 50%-sats 93-95%; pt will desat upon turning but rebounds fairly quickly; lungs coarse-suctioning for small amts of thick white/yellow secretions; ABG's this am within limits for ARDS protocol.\n\nGI/GU: Foley with u/o trending down to 25cc/hr-20mg lasix given at 0500; abd obese, + BS; TF on hold since 0100 for increased residuals. 2 small loose BM this shift.\n\nEndocrine: cont on insulin gtt at 12u/hr all night-BS 100-110's; next bag of TPN to have 20units insulin\n\nSkin: rash noted to face/upper chest-hydrocortisone cream applied; groin and perianal area also noted to be reddened/rash-miconazole powder prn.\n\nPlan: cont to monitor resp status/temp; monitor I/O, will restart TF as tol.; cont q 1-2hr accuchecks, turn pt as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-22 00:00:00.000", "description": "Report", "row_id": 1559416, "text": "MSICU NPN 0700-1900\n\n\nRemains sedated and paralyzed. No changes in sedation made. TOF on 8 0/4 on 7.\n\nSame vent settings. Scant secretions. O2sats 92-95%. ABG pnd. Percussed on bed x3. Tol well.\n\nT max 100.6 ax. Started on Zosyn. No other changes made. Chest CT scan done. Awaiting .\n\nTFs inc to 20cc/hr (not to be advanced further). No residuals as yet. Passing sm amt liq via rectal bag. UO adequate. Continues on TPN.\n\nFSs 90s then dropped to 68. Insulin gtt off at present. Will restart per protocol when FSs>100.\n\nVisitors in most of afternoon. Husband updated.\n\n" }, { "category": "Nursing/other", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 1559427, "text": "Respiratory Care\nPt remained intubated on a/c 350 x 36 70% 22 peep with no remarkable changes overnight. Breath sounds are coarse but suctioning mnimal secretions. Given albuterol and atrovent inhalers as ordered. ABGs with acceptable oxygenation and respir. acidiosis.\n" }, { "category": "Nursing/other", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 1559428, "text": "MICU/SICU NPN HD #12\nEvents: FiO2 reduced to 60%. Tachycardic all day, escalating to 140's-150's this PM. EKG obtained x2, pt received total of 1L NS in boluses, and 5mg IV Lopressor x3 with minimal effect. A bedside echocardiogram was also obtained.\n\nS/O:\n\nNeuro: pt remains sedated with fentany and midazolam, and paralyzed with cisatracurium, PNS with 8 mA on right face\n\nResp: pt remains intubated on AC 35x350x0.6/+22, last ABG 7.24/72/60/0/32, SpO2 88-95% on these settings, LS coarse, suctioned q2-3h for minimal secretions\n\nCV: HR 116-152 ST, EKG obtained x2, BP 96-148/70-90, CVP 16-20 (adjusted CVP = ), plwase see flowsheet for data\n\nSkin: rash on face and trunk much improved today, skin tear on sacrum dressed with Duoderm, eccymotic area over LUQ more diffused today\n\nGI/GU: abd obese, soft, hypoactive BS, Peptamen VHp infusing at 30cc/h with goal rate of 55cc/h, FOley patent for clear yellow urine in adequate amts\n\nLines: right radail art line day #12, left SC TLCL day #13\n\nID: afebrile on Levofloxacin, Linezolid & Zosyn, abx changed today to Levofloxacin, Vanco, Amikacin and Aztreonam\n\nSocial: family meeting scheduled for this PM to update family and discuss plan\n\nA:\n\naltered breathing r/t acute inflammatory process\nimpaired gas exchange r/t acute pulmonary process\nhigh risk for infection r/t invasive lines, ETT, indwelling catheter\n\nP:\n\ncontniue to monitor hemodynamic/respiratory status, continue abx as ordered and follow micro data, continue nutritional support as reccomended, continue to provide emotional support to family, transfuse 1U PRBC\n" }, { "category": "Nursing/other", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 1559429, "text": "respiratory care\npt weaned fio2 to 60%. Remains on A/C 350 x 36 peep22 . Pip still elevated. Abg, 724/72/60/32/89. B.S. coarse with min. secrections. tachycardic most of shift. family meeting this pm.\n" }, { "category": "Radiology", "chartdate": "2167-02-27 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 822331, "text": " 1:00 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: CHARCOAL ASPIRATION AND MULTIDRUG INGESTION ASSESS FOR CHOLECYSTITIS AHD OR HEPATITIS\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ARDS s/p intubation, now with fevers and elevated LFTs\n REASON FOR THIS EXAMINATION:\n Please evaluate for cholecystitis and/or hepatatis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ARDS, intubated, fevers and elevated LFT's.\n\n COMPLETE ABDOMINAL ULTRASOUND: Limited views of the liver are unremarkable\n without evidence of focal or texture abnormalities. The gallbladder is\n unremarkable without evidence of stones or edema. The common duct is not\n dilated at 4 mm. The right kidney measures 9.6 cm. The left kidney measures\n 12.0 cm. There is no evidence of stones, hydronephrosis, or masses. The\n flow within the portal vein is hepatopetal.\n\n IMPRESSION: No evidence of cholelithiasis or cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 822080, "text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess any interval change. Still intubated. Now wi\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt\n , aspiration, likely chemical pneumonitis, ARDS. Please assess interval\n change\n REASON FOR THIS EXAMINATION:\n Please assess any interval change. Still intubated. Now with ventilator\n associated pna based on sputum cx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 32-year-old female status post suicidal attempt with chemical\n pneumonitis and ARDS.\n\n AP SINGLE VIEW OF THE CHEST: Compared to .\n\n There is again noted an ET tube in good position. There is a left subclavian\n central line with the tip in the upper SVC. Again noted are two mediastinal\n wires. There is an ET tube and a feeding tube extending below the diaphragm\n in the stomach. The cardiac, mediastinal and hilar contours are obscured by\n the diffuse bilateral opacities which are unchanged when compared to the\n previous study.\n\n IMPRESSION: Unchanged appearance of bilateral diffuse opacities throughout the\n lungs consistent with chemical pneumonitiis and long standing ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-22 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 821829, "text": " 2:53 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: interval change in ARDS patient, r/o worsening effusions\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ARDS s/p charcoal aspiration and multidrug ingestion.\n Now w/ blossoming cavitary infiltrates on CXR in RML and worsening hypoxia,\n hypercarbia. please assess for interval change since last CT\n REASON FOR THIS EXAMINATION:\n interval change in ARDS patient, r/o worsening effusions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post charcol aspiration and multidrug ingestion with\n worsening hypoxia and hypercarbia.\n\n TECHNIQUE: Helically aquired contiguous axial images from the lung apices to\n the diaphragms were obtained following the administration of 100 cc of IV\n Optiray. Nonionic contrast was used secondary to patient's debilitation.\n\n COMPARISON: .\n\n FINDINGS: Multiple small lymph nodes are identified within the pretracheal,\n prevascular, and hilar regions bilaterally. No enlarged axillary lymph nodes\n are identified. There has been slight interval increase in size of small\n bilateral pleural effusions, right greater than left. There is dilatation of\n the pulmonary artery trunk which measures 3.4 cm in diameter, suggesting\n pulmonary arterial hypertension. The thoracic aorta is unremarkable. The\n heart and pericardium are within normal limits.\n\n Lung window images reveal extensive diffuse areas of consolidation and ground\n glass opacity. Compared to the previous study, there appears to be interval\n progression of cystic changes within both lungs. Additionally there is\n evidence of bronchiectasis bilaterally. Some of the areas of previously\n identified ground glass opacity appear more consolidated on the current study.\n An ET tube is seen with tip terminating at the level of the aortic arch.\n Airways appear patent to the level of the segmental bronchi bilaterally.\n\n In the imaged portion of the upper abdomen, the liver, spleen, gallbladder,\n pancreas, adrenal glands, and kidneys appear unremarkable. An NG tube is seen\n with tip in the proximal duodenum.\n\n Bone windows demonstrate no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1) Extensive diffuse areas of consolidation and ground glass opacities with\n progressive cystic changes noted. These findings are consistent with the\n patient's history of chemical pneumonitis complicated by ARDS.\n\n 2) Dilatation of the main pulmonary arterial trunk, suggestive of pulmonary\n arterial hypertension.\n (Over)\n\n 2:53 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: interval change in ARDS patient, r/o worsening effusions\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3) Interval increase in size of small bilateral pleural effusions, right\n greater than left.\n\n 4) Prominent mediastinal and hilar lymph nodes most likely due to reactive\n lymphadenopathy.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-25 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 822164, "text": " 8:00 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please r/o pulmonary emboli. Thank you.\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ARDS s/p charcoal aspiration and multidrug ingestion.\n Evidence of fibrosis/cystic changes. Now with unexplained tachycardia, right\n sided heart strain on EKG and echo.\n REASON FOR THIS EXAMINATION:\n Please r/o pulmonary emboli. Thank you.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia and right heart strain on echocardiogram.\n\n TECHNIQUE: Pre and post contrast images were obtained through the lungs. 100\n cc Optiray was administered. Nonionic contrast was provided given the patiens\n debility. Multiplanar reformats were constructed.\n\n COMPARISON: .\n\n CT ANGIOGRAM OF THE CHEST:\n\n There is stranding in both axilla. There are several prevascular lymph nodes\n that measure up to 15 mm. Non-enlarged paratracheal and hilar lymph nodes are\n present.\n\n The main pulmonary artery measures 3.5 cm which is enlarged but unchanged from\n the prior exam. The patient was on ventilatory support for the exam so there\n is respiratory artefact. There is only adequate opacification of the pulmonary\n arteries to the lobar branches. There is no large central or lobar pulmonary\n embolus. There is suboptimal evaluation of the segmental pulmonary arteries\n but there are no findings concerning for pulmonary embolus. Again seen within\n the lung fields are confluent areas of septal thickening and ground glass\n opacities, not significantly changed from the prior examination. An area of\n consolidation within the superior segment of the right lower lobe posteriorly\n contains air bronchograms. Bilateral effusions are unchanged. There is no\n pneumothorax.\n\n IMPRESSION:\n 1. No central or lobar pulmonary embolus. The more distal pulmonary arteries\n are incompletely assessed.\n 2. New peripheral consolidation in the right superior segment of the right\n lower lobe posteriorly.\n 3. Continued diffuse lung disease with cystic and fibrotic changes, not\n significantly changed from the prior study.\n (Over)\n\n 8:00 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please r/o pulmonary emboli. Thank you.\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2167-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821657, "text": " 9:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS. Please assess interval change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32 y/o woman with ARDS status post suicide attempt .\n\n AP PORTABLE SUPINE SINGLE VIEW of the chest is compared to similar view from .\n\n FINDINGS: The ET tube is in unchanged position. There is again noted a left\n subclavian central line with the tip in the upper SVC. There is an NG tube,\n which is extending beyond the limits of the radiograph in the stomach. The\n other probe is now located in the stomach. There is again noted diffuse\n pulmonary edema with some fibrotic changes, which are consistent with\n longstanding ARDS. There are two opacities, one in the right mid lung zone\n and the other in the left upper lung zone, which have lucencies within them,\n suggesting cavitation. This could represent superimposed pneumonia. CArdiac,\n mediastinal and hilar contours are unchanged compared to the previous study.\n\n IMPRESSION:\n 1. Diffuse pulmonary edema with fibrotic changes that suggest longstanding\n ARDS.\n 2. Two opacities with suggestion of cavitation, one in the right mid lung zone\n and the other in the upper lung zone. These findings may represent\n superimposed pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821871, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS. Please assess interval change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32 y/o female with respiratory failure s/p suicidal attempt.\n\n AP SUPINE SINGLE VIEW CHEST is compared to AP semi-erect view of the chest\n from .\n\n FINDINGS: There is again noted left subclavian central line with the tip in\n the upper SVC. Again noted 2 mediastinal wires. There is an NG tube and\n another tube both with the tip in the duodenum. The cardiac and mediastinal\n contours are obscured due to the diffuse pulmonary opacities. There is\n interval slight decrease in the lung volumes, however, the diffuse opacities\n are unchanged.\n\n IMPRESSION: 1) Unchanged appearance of diffuse bilateral pulmonary opacities\n likely due to chemical pneumonitis complicated by ARDS. Findings\n suggestive with areas of fibrosis. 2) NG tube and other gastric tube are\n located in duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821151, "text": " 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: daily portable x-ray to evaluate ARDS\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis\n REASON FOR THIS EXAMINATION:\n daily portable x-ray to evaluate ARDS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of respiratory distress, intubation and line placement.\n\n PORTABLE AP CHEST: Endotracheal tube is 3 cm above carina. Left subclavian CV\n line is in proximal SVC. NG tube is in stomach. There are low lung volumes.\n Heart size is normal. Since the previous film of , there has been\n probable increase in the extent of the bilateral pulmonary opacities which\n involve both lungs diffusely in all lobes, consistent with\n aspiration/pulmonary consolidation/ARDS. External wires and surgical clips in\n the neck as previously noted.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-16 00:00:00.000", "description": "N-G TUBE PLACEMENT (W/ FLUORO)", "row_id": 821231, "text": " 10:49 AM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: please place a post-pyloric NG tube\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ARDS, pancreatitis, wish for tube feeds while intubated\n REASON FOR THIS EXAMINATION:\n please place a post-pyloric NG tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pancreatitis, ARDS, tube feeds requirement.\n\n POST PYLORIC NG TUBE PLACEMENT: Preliminary scout film shows orogastric tube\n lying within the body of the stomach. Under direct fluoroscopic guidance, a\n - nasogastric tube was advanced using a guide wire into the\n stomach and then into the third portion of the duodenum. Positioning was then\n verified with the injection of 60 cc of air and a spot film was taken.\n\n The tube was then secured to the nose using tape. The orogastric tube was\n left in place to be removed at the primary team's discretion.\n\n IMPRESSION:\n Successful placement of post pyloric feeding tube under fluoroscopic guidance.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-16 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 821211, "text": " 11:18 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MULTIPLE MEDICATION OVERDOSE, ARD, PANCREATITIS\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ARD and pancreatitis s/p multiple medication overdose\n REASON FOR THIS EXAMINATION:\n please check pancreas for necorsis by pancreatitis protocol and evaluate lungs\n for ARDS\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple medication overdose, with pancreatitis and acute\n respiratory distress.\n\n TECHNIQUE: Axial images of the chest, abdomen, and pelvis were acquired\n helically from the lung apices through the pubic symphysis, before and after\n administration of 150 cc of Optiray contrast. Non-ionic contrast was used\n secondary to the patient's debility. There were no adverse reactions to\n contrast administration.\n\n FINDINGS: Reference is made to the portable AP chest x-ray from .\n\n CT OF THE CHEST WITH IV CONTRAST: Again seen are sternal wires. The\n orogastric and post-pyloric feeding tubes in appropriate positions. The\n endotracheal tube is present in satisfactory position. There are extensive\n bilateral areas of ground-glass opacity and consolidation consistent with\n ARDS. There are small bilateral pleural effusions. No pericardial effusion\n is seen. Oral contrast is seen within the thoracic esophagus, suggestive of\n possible aspiration. There are multiple prominent mediastinal lymph nodes,\n which are likely reactive.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: No focal hepatic lesions are identified.\n The spleen, adrenal glands, kidneys, stomach, and intra-abdominal loops of\n small and large bowel are unremarkable. The gallbladder is mildly distended,\n but there is no adjacent stranding to suggest acute cholecystitis. The\n pancreas enhances symmetrically without adjacent fluid collection. There is\n minimal stranding adjacent to the pancreatic tail, consistent with the\n patient's known pancreatitis. There is no ascites or pathological mesenteric\n or retroperitoneal lymphadenopathy.\n\n CT OF THE PELVIS WITH IV CONTRAST: The appendix, distal ureters, sigmoid\n colon, and rectum are within normal limits. There is a small amount of free\n fluid within the pouch of . The bladder contains a Foley catheter.\n There is no pathological inguinal or pelvic lymphadenopathy.\n\n No suspicious lytic or sclerotic osseous lesions are identified.\n\n IMPRESSION:\n (Over)\n\n 11:18 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MULTIPLE MEDICATION OVERDOSE, ARD, PANCREATITIS\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1) Stranding adjacent to the tail of the pancreas consistent with patient's\n known pancreatitis. No peripancreatic fluid collection or hematoma or\n abnormal pancreatic perfusion.\n\n 2) ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-02-17 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 821362, "text": " 2:32 PM\n UNILAT UP EXT VEINS US Clip # \n Reason: Significant neck/shoulder swelling, pls assess for DVT.\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 yo F s/p suicide attempt with multiple ingestions, s/p charcoal aspiration,\n ARDS with subclavian placed , ongoing fevers.\n REASON FOR THIS EXAMINATION:\n Significant neck/shoulder swelling, pls assess for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ARDS, significant neck/shoulder swelling.\n\n LEFT UPPER EXTREMITY ULTRASOUND: 2D, color and Doppler wave forms were\n obtained of the left internal jugular, subclavian, axillary, brachial and\n basilic veins. Normal wave forms, compressibility and augmentation was\n demonstrated. No intraluminal thrombus was identified.\n\n IMPRESSION: No evidence of left upper extremity deep vein thrombosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-02-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 822196, "text": " 8:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt\n , aspiration, likely chemical pneumonitis, ARDS. Please assess interval\n change\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32 year old woman with respiratory failure status-post suicidal\n attempt.\n\n AP SUPINE SINGLE VIEW OF THE CHEST is compared to . Allowing for\n differences in technique, there is no significant interval change in the chest\n radiograph. Again noted is cystic and fibrotic changes causing diffuse\n opacities throughout the lungs and obscuring the cardiomediastinal contours.\n There is an NG tube with the tip in the stomach or in the first portion of the\n duodenum. There is a feeding tube with the tip in the stomach. The left\n subclavian central line and ET tube are in unchanged positions.\n\n IMPRESSION: 1)There is no interval change in the appearance of the chest\n radiograph. 2)Bilateral cystic and fibrotic changes throughout the lungs\n consistent with chemical pneumonitis and long-standing ARDS. 2) Small right\n pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821099, "text": " 1:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis\n REASON FOR THIS EXAMINATION:\n pls assess\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: History of respiratory distress and intubation and CV line placement.\n The endotracheal tube is 5 cm above the carina. Left subclavian CV line is in\n proximal SVC. There are low lung volumes. There are bilateral ill defined\n and linear densities possibly related to aspiration but difficult to evaluate\n on this film due to the low lung volumes. Evaluate on follow up film.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821535, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT and line placement\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS. Please assess interval change\n REASON FOR THIS EXAMINATION:\n interval change, harder to ventilate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 32-year-old woman in respiratory distress, status post suicidal\n attempt.\n\n COMPARISON: .\n\n FINDINGS: AP supine single view of the chest. The ET tube is in the same\n position. The left subclavian central venous catheter is located in the\n superior SVC and is unchagned in position. The NG tube is unchanged in\n position. There is interval pulling of esophageal probe which is located in\n distal esophagus. The cardiac, mediastinal and hilar contours are hardly\n visualized and are unchanged. There is again onted diffuse patchy bilateral\n lobular opacities unchanged when compared to the previous study.\n\n IMPRESSION: Unchanged appearance of bilateral patchy opacities. No\n significant change in the appearance of the chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821799, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS. Please assess interval change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n Compared to .\n\n CLINICAL INDICATION: Chemical pneumonitis and ARDS.\n\n An endotracheal tube remains in place, currently terminating about 4.5 cm\n above the carina with the neck in a flexed position. Left subclavian vascular\n catheter and feeding tube and nasogastric tube remain in satisfactory\n position. The cardiac and mediastinal contours are stable.\n\n There has been slight improvement in the degree of diffuse pulmonary\n opacification. Note is made of multiple underlying cystic abnormalities\n within both lungs. No pneumothorax is evident. Left apical pleural opacity\n is likely due to pleural fluid.\n\n IMPRESSION:\n 1. Slight improvement in diffuse bilateral pulmonary opacities with\n associated cystic lucencies, likely due to history of chemical pneumonitis\n complicated by ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 821493, "text": " 2:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: R/O SBO, FREE AIR\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ARDS, HIGH ABD PRESSURES\n REASON FOR THIS EXAMINATION:\n R/O SBO, FREE AIR\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: ARDS and high abdominal pressures.\n\n NG tube is in distal antrum. Feeding tube is in fundus of stomach. There is\n some retained contrast throughout the colon which is unremarkable. No\n diagnostic abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821335, "text": " 8:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS. Please assess interval change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 32-year-old woman with respiratory distress status post\n suicidal attempt.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT SINGLE VIEW OF THE CHEST: The ET tube, left subclavian\n central line are in unchanged position. There is interval change of the NG\n tube and feeding tube which extend below the level of the diaphragm in the\n stomach. The radiograph is difficult to compare due to slight lordotic\n projection in the new radiograph. There is a suggestion of increased\n atelectasis of the bases and low lung volumes which may be only due to\n technique. The bilateral diffuse pulmonary edema is unchanged when compared\n with to the previous study.\n\n IMPRESSION: 1. There is no significant interval change. 2. Low lung volumes\n may be secondary to the lordotic projection obtained in the new study.\n 2. Tubes and lines in satisfactory position. No evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821217, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32 y/o woman with respiratory distress s/p suicidal attempt.\n\n COMPARISON: .\n\n AP SUPINE VIEW CHEST: There is an ETT, in proper position. There is a left\n subclavian central line with the tip in mid SVC. The cardiac, mediastinal and\n hilar contours are obscured due to the consolidations. There are bilateral\n diffuse alveolar opacities which are unchanged when compared to the previous\n study and consistent with ARDS. There is interval increase in the lung\n volumes. No obvious pleural effusions although this is a supine film.\n\n IMPRESSION: There is slight improovement in the lung volumes. Continued\n appearance of bilateral diffuse alveolar opacities consistent with ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2167-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821435, "text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ADULT RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with respiratory distress, s/p suicide attempt ,\n aspiration, likely chemical pneumonitis, ARDS. Please assess interval change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 32-year-old female with respiratory distress status post\n suidical attempt.\n\n COMPARISON: .\n\n FINDINGS: AP portable semi-upright view of the chest. There is again noted a\n left subclavian central line with the tip in the mid-SVC in unchanged\n position. The NG tube is difficult to visualize. The esophageal probe in the\n stomach. The cardiomediastinal and hilar contours are unchanged in appearance.\n There is a moderate increase in lung inflation which could be due to\n improvement or due to change in ventilatory settings. There is no evidence of\n pneumothorax.\n\n IMPRESSION: Slight increase in lung inflation could be due to improvement or\n due to change in ventilatory settings (eg. PEEP).\n\n" }, { "category": "Echo", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 76075, "text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade.\nHeight: (in) 64\nWeight (lb): 225\nBSA (m2): 2.06 m2\nBP (mm Hg): 105/72\nHR (bpm): 130\nStatus: Inpatient\nDate/Time: at 14:45\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: The right ventricular cavity is moderately dilated. There is\nsevere global right ventricular free wall hypokinesis. There is abnormal\nseptal motion/position consistent with right ventricular pressure/volume\noverload.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild to moderate\n[+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion. There are no echocardiographic\nsigns of tamponade.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The right ventricular cavity is moderately dilated. There is severe global\nright ventricular free wall hypokinesis. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\n3. There is moderate pulmonary artery systolic hypertension.\n4. There is no pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2167-02-26 00:00:00.000", "description": "Report", "row_id": 186612, "text": "Probable sinus tachycardia. Marked left axis deviation. Poor R wave\nprogression - probable normal variant. Inferior T wave changes are\nnon-specific. Low QRS voltages in the limb leads. Since the previous tracing\nof the rate is decreased.\n\n" }, { "category": "ECG", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 186613, "text": "Probable sinus tachycardia\nAbnormal extreme QRS axis deviation\nrSr'(V1) - incomplete right bundle branch block\nPoor R wave progression\nLow R(V2-V4) probably due to right ventricular hypertrophy\nGeneralized low QRS voltages\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2167-02-25 00:00:00.000", "description": "Report", "row_id": 186865, "text": "Sinus tachycardia\nIndeterminate frontal QRS axis\nrSr'(V1) - probable normal variant\nLow R(V2-V4) probably due to right ventricular hypertrophy\nGeneralized low QRS voltages\nSince previous tracing of , rate slower\n\n" }, { "category": "ECG", "chartdate": "2167-02-24 00:00:00.000", "description": "Report", "row_id": 186866, "text": "Supraventricular tachycardia - ? sinus\nMarked left axis deviation\nNo previous tracing\n\n" } ]

[ { "category": "Echo", "chartdate": "2188-05-19 00:00:00.000", "description": "Report", "row_id": 90867, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.Bioprosthetic aortic valve replacement. Shortness of breath/orthopnea.\nHeight: (in) 66\nWeight (lb): 100\nBSA (m2): 1.49 m2\nBP (mm Hg): 155/69\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 11:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No LA mass/thrombus (best excluded by\nTEE).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Right pleural\neffusion.\n\nConclusions:\nThe left atrium is moderately dilated. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). There is mild symmetric left\nventricular hypertrophy with normal cavity size and regional/global systolic\nfunction (LVEF>55%). Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). A bioprosthetic aortic valve\nprosthesis is present. The aortic valve prosthesis appears well seated, with\nnormal leaflet/disc motion and transvalvular gradients. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen. There is mild to moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global and regional biventricular systolic\nfunction. Well seated aortic valve bioprosthesis with normal gradient.\nMild-moderate mitral regurgitation. Pulmonary artery hypertension. Increased\nPCWP.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis IS recommended. Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-23 00:00:00.000", "description": "PLEURAL ASP BY RADIOLOGIST", "row_id": 1243715, "text": " 3:30 PM\n PLEURAL ASP BY RADIOLOGIST; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please tap pleural effusion for diagnosis of malignancy vers\n Admitting Diagnosis: COPD EXACERBATION\n ********************************* CPT Codes ********************************\n * PLEURAL ASP BY RADIOLOGIST GUIDANCE FOR /ABD/PARA CENTESIS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pleural effusion ? malignancy\n REASON FOR THIS EXAMINATION:\n Please tap pleural effusion for diagnosis of malignancy versus infection. Thank\n you\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Ultrasound-guided thoracentesis.\n\n INDICATION: 81-year-old female with right pleural effusion. Question\n malignancy. Request diagnostic and therapeutic right thoracentesis.\n\n COMPARISON: CT chest dated .\n\n OPERATORS: Dr. and Dr. . Dr. was\n present for the entire duration of the procedure.\n\n PROCEDURE: After explaining the risks, benefits and alternatives to the\n procedure, written informed consent was obtained from the patient. The\n patient was seated on the ultrasound table. Limited son images of the\n right lower hemithorax were obtained which demonstrated a small right pleural\n effusion. An appropriate skin entry site was marked and the overlying skin\n was prepped and draped in the usual sterile fashion. Buffered 1% lidocaine\n solution was used to anesthetize the skin, subcutaneous soft tissues and the\n parietal pleura. Under real-time son guidance, a 5 French \n centesis catheter was advanced into the right pleural cavity. There was\n immediate return of amber-colored pleural fluid. A sample of the fluid was\n sent for microbiological, biochemical and cytological analysis. Following\n this, we connected the centesis needle to a Vacutainer and drained about\n 350 mL of right pleural fluid.\n\n The patient tolerated the procedure well without any immediate periprocedural\n complications.\n\n IMPRESSION: Successful right thoracentesis with removal of 350 mL of pleural\n fluid. Laboratory analysis pending at this time.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-19 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1243154, "text": " 10:00 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate rll infiltrate, r/o pulm malignancy vs pna\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with h/o tobacco abuse, copd, worsening resp status and\n persistent RLL infiltrate\n REASON FOR THIS EXAMINATION:\n evaluate rll infiltrate, r/o pulm malignancy vs pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT 11:00 A.M. ON \n\n HISTORY: 81-year-old woman, smoker, COPD, with worsening respiratory status\n and persistent right lower lobe infiltrate.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n the need for intravenous contrast reconstructed as contiguous 5- and\n 1.25-mm thick axial and 5-mm thick coronal, and 8-mm thick axial MIP images\n reviewed in the absence of prior chest CT.\n\n FINDINGS: Moderate right and small left nonhemorrhagic pleural effusions\n layer posteriorly. In addition to asbestos-related pleural plaques, some\n calcified, such as the largest adjacent to the right middle lobe, 2:40, and\n others on both sides of the posterior chest, 2:41, there is a suggestion of\n even greater pleural thickening in the right posterior pleural sulcus which\n raises concern for pleural tumor. There is no indication of pulmonary\n fibrosis. A roughly elliptical opacity in the right middle lobe sitting on an\n elevated aspect of the right major fissure has both the morphology--short,\n nodular branching extensions--and also the low attenuation characteristics of\n mucoid impaction, 15 to 18 , but does not really conform to bronchial\n branches, 4:147-185 and 601b:19-12. The only other lung lesion is an\n irregular 4-mm wide nodule in the right middle lobe, 4:166. There is no\n consolidation. The questionned right lower lobe \"infiltrate\" was probably a\n combination of the middle lobe lesion and superimposed, moderate right pleural\n effusion. Motion artifact makes it difficult to say whether mild bronchial\n wall thickening is present, but there is no substantial bronchiectasis.\n\n The only enlarged central lymph node is in the right lower paratracheal\n station, 13 mm across, 2:27. The caliber of the intrapericardial pulmonary\n artery, 31 mm, suggests pulmonary arterial hypertension. The patient has had\n median sternotomy, coronary bypass grafting and aortic valve replacement.\n Moderate cardiomegaly is mostly due to enlarged atria.\n\n Atherosclerotic calcification is most pronounced at the origin of the left\n subclavian artery, but is scattered throughout head and neck vessels and the\n normal size thoracic and abdominal aorta.\n\n IMPRESSION:\n 1. Despite asbestos-related pleural plaques found elsewhere, moderate right\n pleural effusion and more pronounced pleural thickening in the right lower\n (Over)\n\n 10:00 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate rll infiltrate, r/o pulm malignancy vs pna\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n chest raise concern for malignant mesothelioma or adenocarcinoma in the right\n pleural space.\n 2. Lesion in right middle lobe could be an atypical mucoid impaction, but\n endobronchial tumor is a reasonable alternative.\n\n PET CT scanning is recommended for evaluation of both lung and pleural\n lesions.\n\n 3. Possible pulmonary arterial hypertension.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243076, "text": " 6:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 81F with sob\n REASON FOR THIS EXAMINATION:\n pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Shortness of breath. Question pneumonia.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, portable AP upright.\n\n FINDINGS: The patient is status post coronary artery bypass graft surgery.\n The heart appears likely at the upper limits of normal size although not\n optimally assessed. The mediastinal contours are unremarkable. There is a\n confluent right infrahilar opacity in the right lower lung with Kerley B lines\n and blunting of the right cardiophrenic angle, quite asymmetric. Patchy\n retrocardiac opacity is less specific but an additional focus of pneumonia\n could be considered versus atelectasis. There is mild background perihilar\n fullness suggesting pulmonary venous hypertension or slight fluid overload,\n but not substantial. Each costophrenic sulcus is blunted which may suggest\n pleural effusions.\n\n IMPRESSION: Extensive right infrahilar opacity worrisome for pneumonia.\n Follow-up radiographs are recommended to show resolution. Patchy retrocardiac\n opacity, possibly atelectasis or pneumonia. Findings also suggestive of mild\n vascular congestion or fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-25 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1243861, "text": " 9:34 AM\n CT CHEST W/CONTRAST Clip # \n Reason: change in right middle lobe mass size, change in pleural arc\n Admitting Diagnosis: COPD EXACERBATION\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with mass in right middle lobe and s/p removal of pleural\n effusion and diuresis\n REASON FOR THIS EXAMINATION:\n change in right middle lobe mass size, change in pleural architecture?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with mass in the right middle lobe, status post\n removal of pleural effusion, and diuresis; evaluate for change in right middle\n lobe mass size, change in pleural architecture.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images of the chest were performed with the\n administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n FINDINGS: Small right and trace left non-hemorrhagic pleural effusions are\n improved since the prior exam. Note is again made of asbestos-related\n pleural plaques, some of which are calcified. The pulmonary vasculature\n appears unremarkable. There is atherosclerotic calcification within the\n thoracic aorta. Right main pulmonary artery measures 31 mm, suggesting\n pulmonary arterial hypertension. Cardiomegaly is also noted. Right\n paratracheal lymph nodes are unchanged from the prior exam measuring upto 9mm\n in short axis diameter. There are multiple areas of mucoid impaction scattered\n throughout the lungs bilaterally ($eries 4: Images 132;135;145;147;149).\n Bronchial wall thickening is noted in the right lower lobe as well.\n\n Multiple sub-5mm pulmonary nodules (Series 603: Images 9, 16; 22; 25; 27) are\n unchanged.\n An elliptical lesion in the right middle lobe with short nodular branching\n extensions appears most consistent with mucoid impaction, measuring 19 x 11mm,\n previously 24 x 10mm at a comparable level.\n\n IMPRESSION:\n 1. Asbestos-related pleural plaques with improved small right pleural\n effusion and trace left pleural effusion.\n 2. An elliptical lesion in the right middle lobe with short nodular branching\n extensions appears most consistent with mucoid impaction, measuring 19 x 11mm,\n previously 24 x 10mm at a comparable level\n (size comparisons were requested by the consulting pulmonary team).\n Bronchosocpy with direct visualization should be considered to rule out a\n smaller stenotic lesion or endobronchial tumor.\n 3. Possible pulmonary arterial hypertension.\n 4. Multiple areas of mucoid impaction scattered throughout the lungs\n bilaterally as noted above.\n (Over)\n\n 9:34 AM\n CT CHEST W/CONTRAST Clip # \n Reason: change in right middle lobe mass size, change in pleural arc\n Admitting Diagnosis: COPD EXACERBATION\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Multiple sub-5mm pulmonary nodules (Series 603: Images 9, 16; 22; 25; 27)\n are unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1243734, "text": " 6:12 PM\n CHEST (PA & LAT) Clip # \n Reason: continued right sided consolidation, PTX?\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p thoracentesis with pleural plaques and consolidation on\n the right.\n REASON FOR THIS EXAMINATION:\n continued right sided consolidation, PTX?\n ______________________________________________________________________________\n WET READ: SJBj SAT 1:09 AM\n No pneumothorax. Interval improvement of right lower lobe opacity.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n CLINICAL HISTORY: 81-year-old woman status post thoracentesis with pleural\n plaques and consolidation on the right. Evaluate change.\n\n FINDINGS: Comparison is made to the previous study from . There\n has been improved aeration at the right base. The heart size is within normal\n limits. There is no pulmonary edema. There are no large pleural effusions.\n There are no pneumothoraces.\n\n\n" }, { "category": "ECG", "chartdate": "2188-05-18 00:00:00.000", "description": "Report", "row_id": 230434, "text": "Atrial fibrillation with a controlled ventricular response. Baseline artifact.\nAnteroseptal myocardial infarction of indeterminate age. Compared to the\nprevious tracing of , atrial fibrillation has replaced sinus rhythm.\nOtherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "RP ANKLE (AP, MORTISE & LAT) RIGHT PORT", "row_id": 1244072, "text": " 5:58 AM\n ANKLE (AP, MORTISE & LAT) RIGHT PORT Clip # \n Reason: fx?\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman s/p MVC with R ankle pain\n REASON FOR THIS EXAMINATION:\n fx?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right ankle .\n\n CLINICAL HISTORY: 26-year-old woman with motor vehicle accident. Right ankle\n pain. Evaluate for fracture.\n\n FINDINGS: The ankle mortise is relatively preserved. There are no signs for\n acute fractures or dislocation. There is no abnormal soft tissue swelling.\n There is no ankle joint effusion. Mineralization is normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244336, "text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: now intubated, with new pulmonary process on , thick sec\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with multi trauma\n REASON FOR THIS EXAMINATION:\n now intubated, with new pulmonary process on , thick secretions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Multi-trauma, intubated with new pulmonary process.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is 5.5 cm above the carina. The NG tube tip is in the\n stomach. The left subclavian line tip is at the level of mid SVC. Heart size\n and mediastinal appear to be unchanged, but there is interval improvement of\n left upper lobe atelectasis as well as mid left lung atelectasis with more\n central position of the mediastinum but with still present minimal left basal\n atelectasis. Surgical clips are projecting over the recently placed internal\n fixator of the right humerus. No appreciable pneumothorax is seen. No\n interval development of substantial pleural effusion is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "LP WRIST(3 + VIEWS) LEFT PORT", "row_id": 1244071, "text": " 5:16 AM\n WRIST(3 + VIEWS) LEFT PORT Clip # \n Reason: fx?\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman s/p mvc with left wrist swelling\n REASON FOR THIS EXAMINATION:\n fx?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left wrist, .\n\n CLINICAL HISTORY: 26-year-old woman status post motor vehicle collision with\n left wrist swelling.\n\n FINDINGS: There are no signs for acute fractures or dislocations. There is\n normal osseous mineralization. There are no bony erosions. A peripheral IV\n catheter seen projecting over the hand soft tissues.\n\n IMPRESSION:\n\n No fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-14 00:00:00.000", "description": "RO HUMERUS (AP & LAT) RIGHT IN O.R.", "row_id": 1244249, "text": " 11:21 AM\n HUMERUS (AP & LAT) RIGHT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n FOREARM (AP & LAT) RIGHT IN O.R.\n Reason: ORIF RIGHT PROXIMAL AND DISTAL HUMERUS, ELBOW AND FOREARM\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: 33 INTRAOPERATIVE FLUOROSCOPIC IMAGES OF THE RIGHT HUMERUS .\n\n COMPARISON: Radiographs .\n\n INDICATION: ORIF right proximal and distal humerus, elbow and forearm.\n\n FINDINGS AND IMPRESSION: Multiple views of the right humerus including the\n shoulder, elbow, and forearm. Status post ORIF of the humerus with antegrade\n intramedullary nail, humeral head screws, and distal interlocking screw.\n Status post ORIF of the ulna with plate and screws. All of the hardware\n appears intact. Improved alignment of the fractures. Total intraoperative\n fluoroscopic imaging time 246.8 seconds. Please see operative report for\n further details.\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 1244057, "text": " 1:00 AM\n CT UP EXT W/O C Clip # \n Reason: preop eval\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with fx\n REASON FOR THIS EXAMINATION:\n preop eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk TUE 5:00 AM\n Comminuted fractures of the proximal and distal right humeral diaphysis, right\n radial head, and right scapula.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 26-year-old female with upper extremity fractures, in need of\n preoperative evaluation.\n\n STUDY: CT of the right upper extremity; images were acquired in a soft tissue\n and bone algorithms. Coronal and sagittal reformatted images were also\n generated.\n\n COMPARISON: Trauma torso CT from .\n\n FINDINGS:\n\n The visualized portions of the right clavicle and right rib cage show no\n fractures.\n\n Within the body of the scapula is a primarily vertically oriented fracture\n which extends into the proximal-most portion of the acromion but does not\n extend into the AC joint or glenohumeral joint (3; 19).\n\n There is a minimally comminuted transverse fracture of the proximal humeral\n metadiaphysis with posterolateral displacement of the major fracture fragment\n by 7 mm. More distally, there is a comminuted fracture of the distal humerus\n with a 2.5-cm long butterfly fragment and with 1 cm distraction between the\n major fracture fragments. There is no extension into the distal articular\n surface.\n\n The visualized portion of the proximal ulna is intact; the visualized portion\n of the radial head demonstrates a minimally-displaced fracture fragment\n sheared off from the lateral aspect of the radial head (3; 124-128).\n\n With respect to fractures described above, there is surrounding hematoma\n within the adjacent musculature, but the adjacent neurovascular bundles appear\n unaffected. No tendon entrapment is appreciated.\n\n The visualized portion of the right lung shows a linear area of ground-glass\n opacity just above the major fissure which was not apparent on prior exam and\n (Over)\n\n 1:00 AM\n CT UP EXT W/O C Clip # \n Reason: preop eval\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n may represent a developing contusion (3;60 and 500b;22). The right upper\n abdomen appears grossly normal and is better evaluated on prior torso CT.\n\n Incidental note is made of prominent subcutaneous soft tissue density about\n the right axilla.\n\n IMPRESSION:\n 1. Right scapular fracture\n 2. Comminuted right humerus fracture as described above.\n 3. Right radial head fracture.\n 4. Small ground glass focus in right upper lung lobe, non specific, but\n compatible with a small lung contusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-06-26 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 1245648, "text": " 11:36 AM\n HUMERUS (AP & LAT) RIGHT; FOREARM (AP & LAT) RIGHT Clip # \n SHOULDER VIEWS NON TRAUMA RIGHT\n Reason: f/u film, s/p ORIF of R humeral fx\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with R humeral fx, s/p ORIF\n REASON FOR THIS EXAMINATION:\n f/u film, s/p ORIF of R humeral fx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right humerus radiograph.\n\n INDICATION: Status post ORIF followup film.\n\n REPORT: Comminuted fracture of the right humerus is being reduced by an\n intramedullary rod which has one proximal and one distal locking screw.\n Partially assessed plate and screw in the ulna is also identified. Overall,\n good anatomical alignment in the femurs. Good anatomical alignment in the\n ulna. Extensive irregularity about the radial head is partially assessed.\n\n CONCLUSION:\n\n Satisfactory appearance status post ORIF.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "RP ELBOW (AP, LAT & OBLIQUE) RIGHT PORT", "row_id": 1244058, "text": " 1:47 AM\n ELBOW (AP, LAT & OBLIQUE) RIGHT PORT; -76 BY SAME PHYSICIAN # \n Reason: ED Portable\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with radial head dislocation\n REASON FOR THIS EXAMINATION:\n ED Portable\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right elbow, .\n\n CLINICAL HISTORY: 26-year-old woman with radial head dislocation.\n\n FINDINGS:\n\n Comparison is made to the previous study performed on .\n\n There is a fracture involving the distal shaft of the humerus. There is also\n a fracture involving the proximal radial shaft. The radial head on the single\n lateral view appears well located. There is an elbow joint effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "RP ELBOW (AP, LAT & OBLIQUE) RIGHT PORT", "row_id": 1244054, "text": " 12:34 AM\n ELBOW (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: ?fx eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 26F with fx s/p reduction\n REASON FOR THIS EXAMINATION:\n ?fx eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with humeral, ulnar, and radial fractures\n post-reduction.\n\n COMPARISON: Elbow radiograph from .\n\n FINDINGS: Evaluation is somewhat limited by overlying cast. Again noted is a\n comminuted fracture of the distal humeral diaphysis with one-half shaft width\n posterior displacement of the distal fracture fragment. Also again noted is\n dislocation of the radiohumeral joint with a comminuted fracture of the radial\n head. A partially comminuted fracture of the mid shaft of the mid ulnar\n diaphysis is also again noted with one width anterior displacement of the\n distal fracture fragment and 1.1 cm overlap of the fracture fragments.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-20 00:00:00.000", "description": "R KNEE (2 VIEWS) RIGHT", "row_id": 1245010, "text": " 6:01 PM\n KNEE (2 VIEWS) RIGHT Clip # \n Reason: pain on medial knee, s/p MVA. R/O fracture\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with knee pain\n REASON FOR THIS EXAMINATION:\n pain on medial knee, s/p MVA. R/O fracture\n ______________________________________________________________________________\n WET READ: MDAg TUE 6:51 PM\n no fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Medial knee pain post-trauma.\n\n AP and two lateral non-standing views of the right knee are normal. No\n fracture, bone destruction, joint space narrowing, osteophytes, or effusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244291, "text": " 3:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT placement\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with post op re intubation\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative reintubation.\n\n FINDINGS: In comparison with study of earlier in this date, the endotracheal\n tube tip lies approximately 3.8 cm above the carina. Other monitoring and\n support devices are unchanged. There is a new area of thick linear\n opacification in the left mid zone, suggestive of atelectasis. There is also\n some increased opacification in the area adjacent to the aortic knob, which\n could be a focus of atelectasis or, in the appropriate clinical setting,\n aspiration. The right lung is clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1245708, "text": " 8:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with multiple ortho injuries s/p ped hit by car. Now febrile\n and tachy\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multiple orthopedic injuries, evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, all monitoring and support\n devices have been removed. There is no pneumothorax, no pleural effusion.\n The lung parenchyma shows normal structure and transparency. There is no\n evidence of pneumonia. Normal size of the cardiac silhouette. Normal\n appearance of the hilar and mediastinal structures.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1244095, "text": " 8:42 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: left SC tlc placement\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with s/p mvc\n REASON FOR THIS EXAMINATION:\n left SC tlc placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old woman with MVC, assess of left subclavian catheter\n placement.\n\n COMPARISONS: .\n\n Endotracheal tube and nasogastric tube are in unchanged position. Left\n subclavian catheter terminates approximately 1 cm beyond the superior\n cavoatrial junction. The lungs are otherwise well expanded and clear.\n Cardiomediastinal contours are unremarkable. Right humeral fracture is\n incompletely imaged.\n\n IMPRESSION: No acute intrathoracic process with left subclavian catheter\n approximately 1 cm beyond the superior cavoatrial junction.\n\n Finding was discussed with Dr. by Dr. at 10 on\n .\n\n" }, { "category": "Radiology", "chartdate": "2130-06-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1244045, "text": " 9:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?epidural\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with ped struck\n REASON FOR THIS EXAMINATION:\n ?epidural\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk MON 11:20 PM\n Punctate foci of hemorrhage in the right inferior frontal and bilateral\n temporal lobes, foci of subarachnoid hemorrhage at bilateral temporal and the\n right frontal lobes, and large right parietal subgaleal hematoma with foci of\n gas consistent with laceration. No evidence of herniation. No acute fractures.\n\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared and\n reviewed.\n\n FINDINGS:\n A large right frontoparietal subgaleal hematoma is noted measuring\n approximately 3.5 cm from the outer table of the skull with foci of air\n consistent with laceration. Furthermore, there are bilateral hyperdensities\n in the sulci within the temporal lobes consistent with subarachnoid hemorrhage\n (2:18). A tiny focus of subarachnoid hemorrhage is also noted in the region\n of the inferior left frontal lobe (400:30). Punctate hyperdense foci are also\n noted in right inferior frontal and bilateral temporal lobes and likely\n represent tiny intraparenchymal hemorrhages (2:10, 2:12, 401B:23, 401B:24,\n 401B:58).\n\n Otherwise, there is no shift of normally midline structures. The basilar\n cisterns are widely patent. -white matter differentiation is well\n preserved. No acute fractures are identified. The visualized mastoid air\n cells and paranasal sinuses are clear.\n\n IMPRESSION:\n 1. Punctate foci of intraparenchymal hemorrhage in the right inferior frontal\n and bilateral temporal lobes.\n 2. Subarachnoid hemorrhage within the temporal lobes bilaterally and the left\n inferior frontal lobe.\n 3. Large right frontoparietal subgaleal hematoma with foci of gas consistent\n with laceration.\n 4. No evidence of herniation. No acute fractures.\n (Over)\n\n 9:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?epidural\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2130-06-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1244046, "text": " 9:56 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with ped struck\n REASON FOR THIS EXAMINATION:\n ?fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk MON 11:29 PM\n Non-displaced fractures of the right C7 and T1 transverse processes. No other\n fractures identified. No prevertebral soft tissue swelling.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: CT head from the same day.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the cervical\n spine without the administration of intravenous contrast. Multiplanar\n reformatted images were prepared and reviewed.\n\n FINDINGS:\n\n C1 through the top of T2 vertebral bodies are visualized. There is reversal\n of the normal cervical lordosis, likely related to placement of the patient in\n a cervical collar. Nondisplaced fractures of the right transverse processes\n of C7 (3:54) and T1 (3:55) are noted. Otherwise, no other acute fractures are\n identified and no subluxation is seen. There is no prevertebral soft tissue\n swelling, though assessment is limited due to the presence of an endotracheal\n tube and orogastric tube. CT is not sensitive for evaluation of thecal sac,\n but the visualized outline of the thecal sac is normal. The visualized lung\n apices are clear.\n\n IMPRESSION: Nondisplaced fractures of the right transverse processes of C7\n and T1 with no evidence of other fractures or prevertebral soft tissue\n swelling.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2130-06-12 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1244047, "text": " 9:57 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: tense abd. hypotension\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with ped struck\n REASON FOR THIS EXAMINATION:\n tense abd. hypotension\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk MON 11:50 PM\n 1. Liver lacerations noted in the right and caudate lobes of the liver with a\n small amount of hemorrhage surrounding the inferior vena cava.\n 2. The medial lobe of the right adrenal gland is not clearly delineated and in\n the region of hemorrhage. As a result, injury to this organ cannot be\n excluded.\n 3. Fractures including the right scapula, right C7 and T1 transverse\n processes, and right proximal and distal humeral diaphysis with right radial\n dislocation.\n 4. ET tube is approximately 1.5 cm from carina. Re-positioning should be\n considered.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: CT head and cervical spine from the same day.\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet\n to the pubic symphysis after administration of IV contrast. Multiplanar\n reformatted images were prepared and reviewed.\n\n FINDINGS:\n\n CT CHEST WITH IV CONTRAST:\n\n The airways are patent to the subsegmental levels. There is mild bibasilar\n atelectasis; otherwise, the lungs are clear with no evidence of consolidation,\n effusion, pneumothorax, contusions, or laceration. The heart is normal in\n size without pericardial effusion. The aorta and great vessels are within\n normal limits. An endotracheal tube is visualized approximately 1.6 cm from\n the carina, and slight withdrawl is recommended. An enteric tube is\n visualized traversing to the stomach. There is no hilar, mediastinal, or\n axillary lymphadenopathy by CT size criteria.\n\n CT OF THE ABDOMEN WITH IV CONTRAST:\n\n Multiple linear hypodensities are noted in the liver and suggestive of\n lacerations with one along the right hepatic vein at the junction of segments\n VII and VIII(2:42), one in segment VII (2:45), and one in the caudate lobe\n (2:46). Additionally, there is hyperdense material surrounding the inferior\n vena cava inferior to the liver and along the intrahepatic portions of the\n inferior vena cava (2:55) consistent with hemorrhage. Additionally, the\n (Over)\n\n 9:57 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: tense abd. hypotension\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n medial limb of the right adrenal gland is not clearly identified in this\n region of hemorrhage, and injury cannot be excluded. No active extravasation\n is identified.\n\n Otherwise, the gallbladder, spleen, stomach, pancreas, left adrenal gland,\n visualized loops of small and large bowel, and bilateral kidneys are normal.\n There is no other free abdominal fluid or air. No mesenteric or\n retroperitoneal lymphadenopathy. The abdominal aorta is normal in caliber and\n contour.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is no free fluid or free air. The\n bladder, rectum, uterus, and sigmoid colon appear within normal limits. No\n pelvic or inguinal lymphadenopathy.\n\n OSSEOUS STRUCTURES: Known nondisplaced right transverse process fractures of\n C7 and T1 are better delineated on the dedicated spine CT. There is a\n comminuted right scapular fracture (2:5). There is also evidence of fractures\n involving the proximal and distal right humeral diaphysis (2:5, scout views)\n and dislocation of the radius.\n\n IMPRESSION:\n 1. Linear hypodensities in the right lobe of the liver and the caudate lobe\n consistent with liver lacerations. Additionally, a small amount of hemorrhage\n is noted surrounding the inferior vena cava inferior to the liver as well as\n in the intrahepatic portion of the IVC. No active extravasation is identified.\n 2. Adjacent to the region of hemorrhage surrounding the inferior vena cava,\n the medial lobe of the right adrenal gland is not clearly identified and\n injury to this structure cannot be excluded.\n 3. Fractures involving the right scapula and right proximal and distal\n humeral diaphysis. Fractures of the right C7 and T1 transverse processes are\n better assessed on the concurrent CT of the cervical spine.\n 4. Low lying endotracheal tube for which slight retraction is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2130-06-12 00:00:00.000", "description": "R ELBOW (AP, LAT & OBLIQUE) RIGHT", "row_id": 1244048, "text": " 9:58 PM\n ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: fxr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 26F with mvc struck\n REASON FOR THIS EXAMINATION:\n fxr\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motor vehicle collision.\n\n TECHNIQUE: Right elbow, 1 view.\n\n COMPARISON: None.\n\n FINDINGS:\n\n Single view of the right elbow demonstrates a comminuted fracture of the\n distal diaphysis of the humerus with displacement of the distal fracture\n fragment by one shaft width radially, and apex angulation of the dominant\n fracture fragments radially. Additionally, there appears to be dislocation of\n the humeroradial joint with a comminuted fracture of the radial head noted. A\n transverse fracture of the midshaft of the ulna is noted with approximately\n one shaft width of ulnar displacement of the dominant distal fracture fragment\n and overlap of the fracture fragments by approximately 1.5 cm.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2130-06-12 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1244042, "text": " 9:40 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n TECHNIQUE: Supine AP view of the chest.\n\n COMPARISON: None.\n\n FINDINGS:\n\n Overlying trauma board limits evaluation. An endotracheal tube tip is low\n lying, with tip approximately 1.5 cm from the carina. An orogastric tube tip\n is within the stomach. The cardiac, mediastinal and hilar contours are\n normal. The lungs are clear. No pleural effusion or pneumothorax is\n identified. Mildly displaced fracture through the superior aspect of the\n right scapula is noted.\n\n IMPRESSION:\n\n 1. Low lying endotracheal tube terminating approximately 1.5 cm from the\n carina. Recommend slight withdrawal. Standard position of orogastric tube.\n\n 2. Right scapular fracture, mildly displaced.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1244134, "text": " 11:11 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: left SC tlc placement\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with s/p mvc\n REASON FOR THIS EXAMINATION:\n left SC tlc placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:22 \n\n HISTORY: 26-year-old woman with cleft mitral valve. Subclavian line placed.\n\n IMPRESSION: AP chest compared to , 8:53 a.m.:\n\n Normal heart, lungs, hila, mediastinum and pleural surfaces. ET tube,\n nasogastric tube, and left subclavian line are in standard placements.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1244221, "text": " 5:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in position. No evidence of vascular congestion or pleural\n effusion. There is some increased prominence of vascular markings along the\n right lateral border of the heart. However, this may merely reflect slight\n change in rotation of the patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 1244132, "text": " 11:11 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT; HUMERUS (AP & LAT) RIGHT PORTClip # \n Reason: please assess for fx dislocation\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with MVC\n REASON FOR THIS EXAMINATION:\n please assess for fx dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVC, question fracture or dislocation.\n\n shoulder 3 vws; humerus, 2 portable vws\n\n There is a comminuted segmental fracture of the humeral diaphysis, with one\n major fracture line in the proximal diaphysis and the other in the distal\n diaphysis. At the distal fracture site, there is considerable comminution,\n with a butterfly fragment. There is slight medial apex angulation and medial\n displacement of the distal fragment at the proximal fracture site and slight\n distraction and angulation of the major fragments (1 cm) at the distal\n fracture site. Slight inferior subluxation of the humeral head, question\n pseudosubluxation, is noted.\n\n The known scapular and radial head fracture is not well visualized on these\n views. Portions of the forearm are slightly obscured by the cast.\n\n" }, { "category": "Radiology", "chartdate": "2130-06-13 00:00:00.000", "description": "R FOREARM (AP & LAT) RIGHT", "row_id": 1244133, "text": " 11:11 AM\n FOREARM (AP & LAT) RIGHT; WRIST(3 + VIEWS) RIGHT Clip # \n Reason: Please assess for fracture/dilocation\n Admitting Diagnosis: PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with MVC\n REASON FOR THIS EXAMINATION:\n Please assess for fracture/dilocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVC, assess for fracture or dislocation.\n\n RIGHT FOREARM, TWO VIEWS. RIGHT WRIST, THREE VIEWS.\n\n RIGHT FOREARM: A cast is in place, obscuring detail. There is a transverse\n fracture of the proximal diaphysis (junction of the proximal and middle third)\n of the ulna, with complete shaft width radial and volar displacement of the\n distal fragment. No angulation or overriding. A radial head fracture is\n suggested at the extreme edge of these views. Assessment of the elbow joint\n is otherwise limited.\n\n RIGHT WRIST: Assessment is limited by overlying cast as well as limitations\n in positioning. No definite malalignment of the distal radioulnar joint.\n Dount frank dislocation. Assessment of the right wrist is otherwise grossly\n unremarkable.\n\n" }, { "category": "ECG", "chartdate": "2130-06-26 00:00:00.000", "description": "Report", "row_id": 228934, "text": "Sinus tachycardia. Possible left atrial enlargement. RSR' pattern in\nleads V1-V2, raising the possibilty of right ventricular conduction delay.\nRate-related ST-T wave changes are seen. Compared to the previous tracing\nof the heart rate has increased, RSR' pattern is seen in leads V1-V2,\nleft atrial enlargement has appeared.\n\n" }, { "category": "ECG", "chartdate": "2130-06-21 00:00:00.000", "description": "Report", "row_id": 228935, "text": "Sinus tachycardia. Non-specific inferior ST-T wave flattening. No previous\ntracing available for comparison.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 774973, "text": " 9:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Motor vehicle trauma.\n\n NON-CONTRAST HEAD CT: There is no mass effect, hemorrhage, displacement of\n normally midline structures, or extra-axial accumulation. Ventricles and\n sulci are not remarkable. Grey and white matter are not unusual. The\n visualized paranasal sinuses are clear.\n\n IMPRESSION: Negative study.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 774974, "text": " 9:39 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o cspine injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o cspine injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Motor vehicle trauma. Rib fractures and pneumothorax.\n\n Contiguous axial images with multiplanar reformatted images.\n\n FINDINGS: There is no evidence of fracture or dislocation. There is\n degenerative disease with disc narrowing at C4-C5, C5-C6, and C6-C7. Gas is\n visualized in the soft tissues of the neck on the right side, consistent with\n a history of pneumothorax.\n\n IMPRESSION: No evidence of fracture or dislocation. Degenerative disease, as\n described.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775012, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for hemo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with rt ptx and chest tube.\n REASON FOR THIS EXAMINATION:\n assess for hemo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with right pneumothorax and chest tube.\n\n PORTABLE AP VIEW OF THE CHEST: Comparison made with prior study performed same\n day approximately 40 minutes earlier. A kinked right-sided chest tube is again\n noted with associated lateral chest wall emphysema extending into the neck.\n The heart size is within normal limits. Patchy opacities are again noted\n within the right mid- and lower lung zone. Fluid and/or pleural thickening is\n present in the right minor fissure. There is prominence of the superior\n paratracheal stripe which in the setting of trauma is worrisome for vascular\n injury and a CT of the chest is recommended. No pneumothorax is identified.\n\n IMPRESSION: No significant change compared to the prior study. Recommend CT of\n the chest with contrast to evaluate for vascular injury.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775008, "text": " 12:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx, sp chest tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with rt ptx and chest tube.\n REASON FOR THIS EXAMINATION:\n ro ptx, sp chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman evaluate pneumothorax and chest tube.\n\n PORTABLE AP VIEW OF THE CHEST: There is a right-sided chest tube with\n extensive associated subcutaneous emphysema. The chest tube is kinked at its\n side hole. The tube terminates in the right midlung zone and overlies the\n right minor fissure. The heart size is within normal limits. There is a patchy\n alveolar opacity overlying the right midlower lung zones possibly representing\n a contusion. There is widening of the superior right paratracheal stripe.\n There is no evidence of pneumothorax.\n\n IMPRESSION: Widening of the right paratracheal stripe in the setting of trauma\n is worrisome for vascular injury and a CT of the chest is recommended for\n further evaluation. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775104, "text": " 1:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p r chest tube removed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with right chest tube removed. pls do upright to eval for\n pneumothorax\n REASON FOR THIS EXAMINATION:\n s/p r chest tube removed\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP:\n\n INDICATION: S/P removal of right chest tube. Evaluate for pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: S/P removal of right chest tube.\n\n Allowing for slight patient rotation, appearances in the heart and mediastinum\n are unchanged since prior examination. There is increased opacification in the\n right lower zone when compared to the prior study. No pneumothorax. There is\n extensive subcutaneous emphysema in the right lateral chest wall as previously\n described.\n\n IMPRESSION: No recurrence of pneumothorax after removal of chest drain.\n Increased opacity at the right lung base may represent acute consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 774990, "text": " 10:50 AM\n FOOT AP,LAT & OBL LEFT; ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: mvc with L foot deformity\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n mvc with L foot deformity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA. Evaluate for fracture.\n\n TWO VIEWS OF THE LEFT ANKLE: There is a nondisplaced transverse fracture of\n the distal left fibula in the region of the ankle mortise. There is a fracture\n of the medial malleolus that is displaced approximately 1 to 2 cm superiorly.\n There is a displaced fracture of the talus which completely disrupts the\n articular surface of the talus. The medial portion of the fractured talus\n remains in close proximity with the displaced fractured segment of the medial\n malleolus. The lateral portion of the fractured talus remains in close\n proximity to the lateral portion of the distal tibia and fibula. There are no\n other definite fractures identified within the midfoot. The calcaneus is not\n well seen secondary to patient positioning.\n\n IMPRESSION: Nondisplaced fracture of the lateral malleolus, displaced fracture\n of the medial malleolus, and displaced fracture of the talus.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 774989, "text": " 10:49 AM\n LUMBO-SACRAL SPINE (AP & LAT); T-SPINE Clip # \n Reason: mid thoracic tenderness- obtain TLS views\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n mid thoracic tenderness- obtain TLS views\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Back pain.\n\n These two exams consist of AP and lateral and cross-table lateral views of the\n thoracic and lumbar spine. No fracture or bone destruction. Generalized\n demineralization. Slight scoliosis probably positional. SI joints and poorly\n visualized hips are probably normal. Residual contrast in renal calyces and\n bladder (Foley catheter in place). Right-sided subcutaneous gas with poorly\n assessed right rib fractures and right PTX.\n\n IMPRESSION: No spine fracture identified. Right rib fracture, PTX, and\n subcutaneous gas.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 775036, "text": " 5:31 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please perform CTA for questionalbe mediastinum\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p high speed MVC. she is currently booked for the OR\n tonight. Can you please page with immediate results. Thanks\n REASON FOR THIS EXAMINATION:\n Please perform CTA for questionalbe mediastinum\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n INDICATION: 58 year old woman status post high speed MVC with mediastinal\n widening on plain chest radiograph. Multiple rib fractures and chest tube.\n\n CT OF THE CHEST WITH CONTRAST; MULTIPLANAR RECONSTRUCTIONS.\n\n COMPARISONS: Comparison is made with prior plain films performed earlier same\n day.\n\n TECHNIQUE: Contiguous serial axial images were obtained from the lung bases\n to the lung apices after the administration of 100 cc of nonionic Optiray\n contrast. Multiplanar reconstructions were performed.\n\n CT OF THE CHEST WITH CONTRAST: There is a right-sided chest tube extending in\n the major fissure and extending superiorly. There is extensive associated\n emphysema within the soft tissues of the right lateral chest wall extending\n posteriorly and cephalad. There is a right hydropneumothorax with dependent\n atelectasis. Multifocal areas of ill-defined parenchymal opacities are\n present likely representing contusions, most prominent in the anterior right\n middle lobe. There are numerous right-sided posterior rib fractures and a\n right scapular fracture. There is deformity of the left anterior chest wall\n but no definite rib fractures are identified. There is prominence to the\n right superior mediastinum representing venous dilatation. The aorta\n demonstrates a normal contour. At the level of the carina multiple small\n linear areas of contrast opacification are present adjacent to the medial wall\n of the descending aorta. These represent prominant bronchial arteries\n resulting from bronchiectasis. There is no definite mediastinal hematoma.\n There is diffuse thickening of the aortic wall throughout its visualized\n course. The visualized heart and great vessels are otherwise grossly\n unremarkable. There is no axillary or mediastinal lymphadenopathy.\n\n MULTIPLANAR RECONSTRUCTIONS: Reconstructions are consistent with the above\n findings and demonstrate no definite evidence of mediastinal injury.\n\n IMPRESSION:\n 1. No evidence of vascular injury. The abnormal contour seen on chest\n radiograph represents venous dilatation (azygous vein).\n 2. Multiple posterior right-sided rib fractures and a right scapular fracture\n are present. A right chest tube and right hydropneumothorax are present.\n (Over)\n\n 5:31 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please perform CTA for questionalbe mediastinum\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n (Cont)\n Multifocal areas of pulmonary contusion and dependent atelectasis are present.\n 3. Bronchiectatsis, primarily in the RML accounting for prominant bronchial\n arteries.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "LO ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.", "row_id": 775047, "text": " 9:11 PM\n ANKLE (AP, LAT & OBLIQUE) LEFT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \n Reason: FX REDUCTION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fracture reduction.\n\n COMPARISON: .\n\n FINDINGS: Fluoroscopic assistance was provided to the surgeon in the\n operating room without the presence of a radiologist. Six spot views are\n obtained during the procedure demonstrating a side plate along the medial\n malleolus of the tibia with multiple screws. Other screws are seen traversing\n the fractured talus. Again noted is a non- displaced distal fibular fracture.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-19 00:00:00.000", "description": "INTRO AORTA FEM/AXIL", "row_id": 775073, "text": " 8:45 AM\n THORACIC Clip # \n Reason: r/o aortic rupture/dissection\n Contrast: OPTIRAY Amt: 175\n ********************************* CPT Codes ********************************\n * INTRO AORTA FEM/AXIL THORACIC ANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p trauma, MVC, question of aortic injury on CT scan\n\n REASON FOR THIS EXAMINATION:\n r/o aortic rupture/dissection\n ______________________________________________________________________________\n FINAL REPORT\n ARCH AORTOGRAM .\n\n ATTENDING RADIOLOGISTS: Dr. and Dr. .\n\n The patient is a 58 year old Hispanic female who is status post a motor\n vehicle collision. She underwent chest X-ray as well as CT angio of the chest\n and transesophageal echo for workup of a possible aortic injury. CT angio was\n not able to rule out an aortic injury, therefore the patient was consented for\n an arch aortogram.\n\n TECHNIQUE: The patient received no premedication for the procedure. She was\n placed in the supine position on the fluoro table. The right groin was\n prepped and draped in the usual sterile manner. 8 cc of 1% lidocaine was\n infiltrated in the region of the right groin and the right femoral artery was\n identified at the level of the mid-femoral head by fluoroscopy. An 18 gauge\n needle was used to puncture the right femoral artery. in the skin was\n made with a scalpel, a wire was passed into the thoracic aorta and the needle\n was exchanged for a 5 French sheath. A multi-sidehole curved catheter was\n placed over the wire and positioned at the level of the proximal ascending\n aorta. A contrast aortogram was performed with four views including AP,\n oblique and lateral.\n\n FINDINGS: The aortic contour was smooth and unremarkable. A right upper lobe\n bronchial artery was noted to be present and corresponded with the\n questionable area on CT angiogram. The innominate, left carotid and left\n subclavian arteries were normal in appearance. The patient tolerated the\n procedure well without the need for additional medication. The sheath was\n removed, pressure was applied for 15 minutes and adequate hemostasis was\n noted. There was no evidence of hematoma or ecchymosis at the puncture site.\n\n IMPRESSION: Normal arch aortogram.\n\n\n (Over)\n\n 8:45 AM\n THORACIC Clip # \n Reason: r/o aortic rupture/dissection\n Contrast: OPTIRAY Amt: 175\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2103-12-20 00:00:00.000", "description": "L CT LOW EXT W/O C & RECONS LEFT", "row_id": 775139, "text": " 8:05 AM\n CT LOW EXT W/O C & RECONS LEFT Clip # \n Reason: eval for occult cuboid fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p mvc with left trimallolar fracture, s/p orif and x fix.\n pls eval for occult cubiod fracture\n REASON FOR THIS EXAMINATION:\n eval for occult cuboid fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left trimalleolar fracture-dislocation. ? cuboid fracture.\n\n COMPARISON: No priors.\n TECHNIQUE: CT of the left ankle with multiplanar reconstructions.\n\n CT OF THE LEFT ANKLE. There is a plate-and-screw assembly through comminuted\n intra-articular fracture of the distal left tibia, as well as an external\n fixating screw traversing the calcaneus. There is a comminuted fracture of\n the anterior calcaneus and anterior portion of sustentaculum tali. No\n fracture is seen within the cuboid or navicular bones.\n\n IMPRESSION: Comminuted fracture involving the anterior aspect of the\n calcaneus and fixated fracture tibia. No fracture of cuboid is appreciated.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 774975, "text": " 9:39 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: r/o injury\n Field of view: 41 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 58 y/o female with MVA. Evaluate for abdominal injury.\n\n TECHNIQUE: Contrast enhanced CT imaging of the abdomen and pelvis with 150\n cc of Optiray. Nonionic contrast is used due to patient allergy. No prior\n studies are available for comparison.\n\n CT ABDOMEN WITH CONTRAST: There are fractures of the 9th, 10th and 11th\n posterior ribs on the right. There is a small pneumothorax present on the\n right with extensive subcutaneous air noted within the right chest and\n abdominal wall. There is no evidence of rib fracture within the visualized\n portions of the lower left rib.\n\n LIver is normal in contour and attenuation with no masses or biliary ductal\n dilatation. The gallbladder is normal in appearance. The spleen is not\n enlarged. There is no evidence of free fluid within the abdomen. THe pancreas\n enhances hemogenously. There are no adrenal masses, both kidneys enhance and\n excrete contrast promptly and symmetrically. There is a small simple renal\n cyst present on the right. There are no renal masses, stones, or\n hydronephrosis. There is no retroperitoneal lymph node enlargement.\n\n The stomach, small bowel and colon show no dilatation or wall thickening.\n\n CT PELVIS WITH CONTRAST: There is no evidence of free fluid within the pelvis.\n The distal ureters are normal in caliber, the urinary bladder, uterus, and\n rectum are unremarkable. There is no pelvic lymph node enlargement.\n\n Bone windows demonstrate fractures in the region of the 9th, 10th, and 11th\n posterior ribs on the right. There are no other suspicious lytic or sclerotic\n lesions identified.\n\n IMPRESSION: Multiple lower rib fractures on the right with small\n pneumothorax and extensive subcutaneous air on the right.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)", "row_id": 774978, "text": " 9:43 AM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: s/p MVC r/o fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p MVC r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old female status post MVA evaluate for fracture.\n\n AP PELVIS: The lower lumbar spine and the superior portion of the pelvis are\n not included on this study. Within the visualized portions of the pelvis and\n hips there is no evidence of fracture, dislocation, bone destruction, bone\n erosion, or suspicious lytic or sclerotic lesions. There are no abnormal\n tissue calcifications. The mineralization is normal. There is normal\n alignment.\n\n IMPRESSION: Incomplete visualization of the pelvis. No evidence of fracture or\n dislocation in the lower pelvis and hips.\n\n AP CHEST RADIOGRAPH: Please note that the apices of both lungs are not\n entirely included in this film. The heart size and mediastinal contours are\n within normal limits. There is increased pulmonary vascularity bilaterally.\n There is astelectasis at the left lung base. There are no pleural effusions.\n There is no free air beneath the diaphragm identified. There are fractures of\n at least three posterior ribs on the right. There is no evidence of a large\n pneumothorax.\n\n IMPRESSION: Multiple rib fractures on the right. Increased pulmonary\n vascularity bilaterally and atelectasis at the left lung base.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-18 00:00:00.000", "description": "LP ANKLE (2 VIEWS) LEFT PORT", "row_id": 775020, "text": " 3:00 PM\n ANKLE (2 VIEWS) LEFT PORT Clip # \n Reason: pt is hemodynamically unstable, please obtain portable left\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n above\n REASON FOR THIS EXAMINATION:\n pt is hemodynamically unstable, please obtain portable left ankle and foot\n films stat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 year old woman with left distal tibia and fibular fracture.\n Hemodynamically unstable.\n\n THREE VIEWS OF THE LEFT ANKLE: Comparison is made with prior study performed\n approximately four hours earlier the same day. There has been interval\n placement of a radiopaque cast which obscures detail. A displaced fracture of\n the medial malleolus is again noted as is the talar fracture. The distal\n tibial fracture is poorly visualized. There is no significant change in\n alignment compared to prior study.\n\n IMPRESSION: There has been no significant change in appearance of the\n bimalleolar and talar fractures. Placement of a cast limits evaluation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2103-12-18 00:00:00.000", "description": "Report", "row_id": 1345451, "text": "NSG ADMIT/TRANSFER NOTE:\nPT IS A 58 Y/O FEMALE UNRESTRAINED DRIVER S/P ROLLOVER IN SUV. +LOC AT SCENE. TRANSFERRED FROM OSH TO FOR FURTHER CARE. HEAD/ABD CT NEG. INJURIES: MULT RT RIB FX'S, RT PNEUMOTHORAX S/P CT PLACEMENT, LT CALCANEAL FX, AND LT TIB/FIB FX. IN ER, PT HAD 2EPISODES OF HYPOTENSION UNRELATED TO NARCS. ?ETIOL. SBP 100'S-->70'S. RESPONDED TO FLD. LLE REDUCED AND BROUGHT TO TSICU FOR ?CVP MONITORING.\nNKDA. MEDS: XANAX FOR SLEEP AND CALCIUM SUPPS.\n\nN: PRIMARY PORTUGUESE. UNDERSTANDS AND SPEAKS ENGLISH. A/OX3. C/O PAIN RT RIBS. GIVEN MSO4 PRN WITH EFFECT.\nCV: RT RAD ALINE PLACED AND NSR 80-100 NO ECTOPY. SBP 100-130'S. LLE WITH WEAKLY PALP PP. RT POST CT TO LWS WITH SM AMT SANG DRAINAGE. -CREPITUS/-LEAK\nR: LUNGS CLEAR THROUGHOUT. 2L O2 VIA NC AND SATS 100%. ENCOURAGED TO C/DB.\nGI: NPO FOR OR. ABD SOFT AND NON TENDER. BS +\nGU: FOLEY DRAINING LT YELLOW IN LG AMTS.\nHEME: HCT 31\nID: AFEBRILE.\nSOC: PT LIVES WITH DAUGHTER IN AND DAUGHTER IS AWARE AND ON THE WAY.\nA/P: HD STABLE AND AWAITING OR-->THEN TO PACU.\n" }, { "category": "Nursing/other", "chartdate": "2103-12-18 00:00:00.000", "description": "Report", "row_id": 1345452, "text": "addendum:\nPT TAKEN FOR CHEST CT TO EVALUATE ? WIDENED MEDIASTINUM. STABLE DURING TRANSPORT AND NOW CURRENTLY PLANNING ON TRIP TO ANGIO TO EVAL ?AORTIC TEAR VS EMBRIONIC VASCULATURE THEN TO OR FOR REPAIR OF TIB/FIB.\n" }, { "category": "ECG", "chartdate": "2103-12-18 00:00:00.000", "description": "Report", "row_id": 172576, "text": "Baseline artifact\nSinus rhythm\nNormal ECG\nNo previous tracing for comparison\n\n" } ]

[ { "category": "ECG", "chartdate": "2168-10-05 00:00:00.000", "description": "Report", "row_id": 281556, "text": "Sinus arrhythmia. Inferoposterior myocardial infarction of indeterminate\nage. Non-specific anterior T wave changes. Compared to the previous tracing\nof the precordial ST segments are flatter.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2192-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767910, "text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p PA cath\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation\n REASON FOR THIS EXAMINATION:\n s/p PA cath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, status post intubation. New placement of SG\n catheter.\n\n Comparison: at 23:58.\n\n FINDINGS:\n\n Dense opacification of the left lung is not substantially different. Air\n space disease has progressed in the region of the right middle lobe. Right\n upper lobe remains clear. There is no pneumothorax. The tip of hte ET tube\n is appropriately located. A right SG catheter is seen with the tip\n approaching the right main pulmonary artery. Pulmonary vascular markings and\n cardiac silhouette remain within normal limits.\n\n IMPRESSION:\n\n Progressive air space disease in the right middle lobe. Continued dense\n opacification in the left lung. Continued follow up is needed with clinical\n correlation--considerations are: Aspiration pneumonia and ARDS.\n\n SG catheter as described above.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767891, "text": " 11:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation- please check tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od\n REASON FOR THIS EXAMINATION:\n s/p intubation- please check tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post intubation. Check tube placement.\n\n PORTABLE AP CHEST: Comparison is made to an exam of 2.5 hours earlier. There\n has been interval placement of an endotracheal tube, with the tip\n approximately 3.7 cm above the carina. There has been interval placement of a\n right sided central venous catheter, with the tip overlying the proximal SVC.\n Again noted is dense consolidation of the left upper lobe, slightly increased\n in size from the previous exam. There is also new involvement of the right\n hilum. The soft tissues and osseous structures are stable.\n\n IMPRESSION:\n 1. Satisfactory placement of endotracheal tube and right sided central venous\n catheter.\n\n 2. Slight interval progression of left lung air space consolidation, with\n new involvement of the right hilum. Etiologies continue to include non-\n cardiogenic pulmonary edema, aspiration pneumonia or pulmonary contusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768499, "text": " 3:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o Pneumothorax. Verify line replacement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od, now 48 hours s/p\n extubation-being treated for aspiration pna. Now s/p left thoracentesis and\n right IJ line change.\n REASON FOR THIS EXAMINATION:\n r/o Pneumothorax. Verify line replacement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P extubation. Treated for aspiration pneumonia. Now s/p left\n thoracentesis and right IJ change. Assess line placement.\n\n PORTABLE SUPINE AP CHEST, ONE VIEW: Since the study of /2 hours earlier,\n there has been interval replacement of a right IJ line with tip in the SVC.\n There is no pneumothorax. There is an NG tube within the stomach. There is no\n CHF, or large pleural effusion. There is interval partial clearing of the\n density seen previously in the left lower lobe. This may represent resolving\n atelectasis or it could be related to interval thoracentesis. There is no\n pneumothorax. Hazy opacity at the right base is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-29 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 768501, "text": " 4:24 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: SWOLLEN LEFT LEG, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with drug overdaose and severe rhabdo with ARF, s/p extubation\n 48 hours ago, now with unilateral swelling of left leg and left arm.. Please do\n LENI on left leg.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Swollen left leg, r/o DVT.\n\n LOWER EXTREMITY VEIN ULTRASOUND: All the deep veins in the left leg from the\n groin region to knee region demonstrate normal flow, compression, augmentation\n and respiratory variation. There is no evidence of DVT.\n\n IMPRESSION: No evidence of above knee DVT in the left lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-07-28 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 768460, "text": " 9:25 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: ? infarct (Ant cerebral? territory), ? hypoxic encephalopath\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man found down after~48hrs, hypoxic to 88% on presentation to ED,\n with rhabdomyolysis, ARF, aspiration PNA and sepsis. Now pt has decreased\n mental status and L leg weakness.\n REASON FOR THIS EXAMINATION:\n ? infarct (Ant cerebral? territory), ? hypoxic encephalopathy. please do DWI\n as well\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with ? of hypoxia for further evaluation.\n\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2 and susceptibility as well as\n diffusion axial images of the brain were obtained. The patient was unable to\n hold still and some of the scans were repeated due to motion.\n\n FINDINGS: There is no evidence of midline shift, mass effect, hydrocephalus.\n No focal signal abnormalities are seen. Diffusion weighted images demonstrate\n no evidence of area of restricted diffusion to indicate acute infarct. The\n vascular flow voids are maintained. Extensive soft tissue changes are seen\n within the sphenoid sinus and soft tissue changes are also noted in the left\n maxillary sinus possibly related to intubation.\n\n IMPRESSION: No evidence of acute infarct or mass effect. No other significant\n abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768492, "text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of resolving pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation-being treated for\n aspiration pna.\n REASON FOR THIS EXAMINATION:\n evidence of resolving pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23 year old man with ARF, rhabdo, s/p intubation, being treated for\n aspiration pneumonia.\n\n CHEST, PORTABLE: Comparison is made to a prior study from earlier the same\n day. The heart is normal in size. The mediastinal and hilar contours are\n unremarkable. The pulmonary vasculature is normal. There are persistent\n opacities in the right lower lobe and in the left lower lobe. No new\n infiltrates are seen. A small left pleural effusion might be present.\n\n IMPRESSION: No change in comparison to a prior study from earlier the same\n day with multiple bilateral patchy opacities consistent with multifocal\n pneumonia.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2192-07-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768450, "text": " 3:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt is s/p NGT placement. ? past GE junction.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation-being treated for\n aspiration pna.\n REASON FOR THIS EXAMINATION:\n pt is s/p NGT placement. ? past GE junction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute renal failure. Status post intubation. Being treated for\n aspiration pneumonia. Status post NG tube placement.\n\n PORTABLE AP CHEST, ONE VIEW: Study is targeted to the lower chest and upper\n abdomen, as requested, for NG tube placement. The sideport of the NG tube is\n within the body of the stomach and tip is in the region of the antrum. There\n is no evidence of bowel obstruction on this single view. There is dense\n consolidation in the left lower lobe with obscuration of the left hemi-\n diaphragm. There is patchy air space opacity at the right base.\n\n IMPRESSION: NG tube in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 768445, "text": " 2:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed or mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man found down x 48hrs, rhabdomyolysis, renal failure, aspiration\n PNA intubated on Ativan and Flagyl, now with decreased responsiveness,\n decreased MS, nonpurposful movements s/p extubation and d/c of sedation.\n REASON FOR THIS EXAMINATION:\n ? bleed or mass\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23 year old found down for 48 hrs, myolysis and renal failure.\n Status post extubation with nonpurposeful movements.\n\n TECHNIQUE: Noncontrast CT of the brain was performed.\n\n FINDINGS: There are no abnormal extra-axial collections, mass affect or shift\n of normally midline structures. There is no intracranial hemorrhage seen. The\n ventricles and sulci are within normal limits. There are no skull fractures\n seen. There is mucosal thickening seen in the sphenoid sinuses. In addition\n there is a small amount of fluid seen in the left mastoid air cell and there\n some coalescence in the mastoid air cells bilaterally.\n\n IMPRESSION: No acute intracranial hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767999, "text": " 4:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: follow progression of ARDS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation-follow ards\n\n REASON FOR THIS EXAMINATION:\n follow progression of ARDS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ARDS.\n\n COMPARISON: .\n\n FINDINGS:\n\n Dense opacity over the left chest is not significantly different. There is\n less air-space density seen in the right lower lung field and the right upper\n lung remains clear. All lines and tubes remain in place and there is no\n pneumothorax.\n\n A suggestion of some pleural thickening at the left apex is noted. This\n should be evaluated on subsequent follow-up and clinical correlation is\n indicated. The mediastinum and cardiac contours are normal and unchanged.\n\n IMPRESSION:\n\n Improvement in air-space process at right. Continued dense opacification left\n lung with new finding being extension of density along the left apex.\n\n No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768473, "text": " 5:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change post extubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation-being treated for\n aspiration pna.\n REASON FOR THIS EXAMINATION:\n interval change post extubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute renal failure. Being treated for aspiration pneumonia. Assess\n post extubation.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison . Since the prior exam, the\n patient has been extubated. There is an NG tube within the stomach. There is\n a right IJ line with tip in the region of the brachiocephalic vein/superior\n SVC junction. There is no pneumothorax. The heart size is within normal\n limits. There is improved aeration of the left upper lobe. There is\n persistent dense opacification in the left lower lobe/retrocardiac region.\n In addition, there are more patchy opacities in the left mid lung zone and\n right lower lobe. Findings are consistent with history of multifocal\n pneumonia. There is a probable small left effusion. No right effusion is\n noted.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767885, "text": " 9:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt found unresponsive\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n pt found unresponsive\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found unresponsive, abdominal pain.\n\n PORTABLE AP CHEST: Note that the right CP angle and right lateral hemithorax\n are not fully included. The heart size and mediastinal/hilar contours are\n unremarkable. There is dense air-space consolidation of the left upper lobe.\n There is no evidence of adjacent rib fractures, pneumothoraces or pleural\n effusions. The right lung field is unremarkable. The soft tissues and\n osseous structures are within normal limits.\n\n SINGLE VIEW OF ABDOMEN: There is no evidence of dilated loops of large/small\n bowel to suggest intestinal obstruction. There is a low-lying gastric antrum.\n There is no evidence of free intraperitoneal air on this single supine view.\n Noted is a Foley catheter overlying the region of the urinary bladder. Soft\n tissues and osseous structures are unremarkable.\n\n IMPRESSION: Probable left upper lobe aspiration pneumonia. The paracentric\n location of this consolidation also raises the possibility of a non-\n cardiogenic pulmonary edema. In the absence of other traumatic findings,\n pulmonary contusions are considered less likely.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-07-24 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 768109, "text": " 4:10 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: question of progressive ARDS vs. aspiration pneumonia\n Field of view: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with h/o heroin abuse who was found unresponsive next\n to open bottle of serax.\n REASON FOR THIS EXAMINATION:\n question of progressive ARDS vs. aspiration pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 23 y/o man with history of heroin abuse, found unresponsive, ?\n progressive ARDS versus aspiration pneumonia.\n\n CT CHEST WITHOUT CONTRAST: Comparison is made to previous films from to\n .\n\n TECHNIQUE: Contiguous helical imaging was obtained from the thoracic inlet\n to the upper abdomen without IV contrast administration.\n\n FINDINGS: Diffuse anasarca is identified. No significant axillary,\n mediastinal or hilar lymphadenopathy is noted. Residual thymus is seen.\n Endotracheal tube is in good position. The heart is not enlarged and there is\n no pericardial effusion. There are moderate bilateral pleural effusions,\n right greater than left. The lung windows demonstrate predominant alveolar\n opacity within the left lung especially seen in nondependent locations. There\n is some patchy alveolar opacities seen within the right lung but the majority\n of the aerated lung is uninvolved. There is bilateral associated compressive\n atelectasis. The airways are patent to the level of the segmental bronchi.\n\n NG tube is in good position terminating within the distal stomach. The\n visualized portions of the liver, spleen, adrenals, pancreas and kidneys are\n normal. Skeletal elements demonstrate no suspicious lytic or sclerotic foci.\n No fractures are appreciated.\n\n IMPRESSION:\n\n Diffuse alveolar opacity within the left lung, with a lesser degree of patchy\n alveolar opacity within the right lung. The asymmetric distribution and\n extensive involvement of nondependent portions of the lungs is unusual\n for isolated ARDS and favors the diagnosis of multifocal pneumonia. Secondary\n complication of infection by ARDS is not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768251, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evolution of right-sided consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation-being treated for\n aspiration pna.\n REASON FOR THIS EXAMINATION:\n evolution of right-sided consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure, possible rhabdomyosis.\n\n COMPARISON: .\n\n A right internal jugular catheter is seen with tip in the superior vena cava.\n An ETT is also visualized with tip 4 cm from the carina. The tip of the ETT\n appears slightly angulated to the left and is up against the left tracheal\n wall. There is improvement in the left-sided diffuse alveolar opacity.\n Persistent unchanged alveolar opacity is seen in the right lower lobe.\n Atelectasis is once again demonstrated at the left base.\n\n IMPRESSION:\n 1) Asymmetric bilateral alveolar pattern, left greater than right, with some\n improvement in the left perihilar region. This is likely due to multilobar\n pneumonia.\n 2) ETT with tip abutting the left lateral tracheal wall. The primary team was\n informed of this finding.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-28 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 768432, "text": " 10:28 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: SWOLLEN LEFT ARM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p drug overdose, with rhabdomyolysis and ARF, s/p extubation\n today with left arm swelling. r/o DVT.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old man status post drug overdose with rhabdomyolysis and\n acute renal failure with left arm swelling.\n\n TECHNIQUE: color flow, scale and pulsed Doppler images were obtained\n from the left upper extremity veins which included left IJ, subclavian,\n axillary, brachial, systolic, and basilar veins.\n\n FINDINGS: scale, color and Doppler images of the examined veins showed\n normal flow, augmentation, compressibility, and wave form. No intraluminal\n thrombus was identified.\n\n IMPRESSION: No evidence of DVT in the examined left upper extremity veins.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-21 00:00:00.000", "description": "MR PELVIS W/O CONTRAST", "row_id": 770278, "text": " 3:06 PM\n MR PELVIS W/O CONTRAST Clip # \n Reason: please evaluate left sciatic notch for possible outlet compr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p heroine OD with ARF requiring HD (resolved) and LLE\n weakness and pain, now with persistent distal LLE parasthesias and weakness and\n localized left gluteal tenderness.\n REASON FOR THIS EXAMINATION:\n please evaluate left sciatic notch for possible outlet compression; piriformis\n swelling an/or fluid collection\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: History of heroin overdose with rabdomyolysis and persistent left\n lower extremity weakness and pain, evaluate left sciatic notch for nerve\n compression.\n\n TECHNIQUE: Multiplanar imaging was performed through the sacrum and posterior\n pelvis, according to the sacral plexus protocol. To better evaluate the left\n gluteal abnormality an attempt was made to perform more imaging of that\n region, but the patient refused to continue so the study was terminated.\n Comparison is made to prior CT and ultrasound of and prior lumbar\n spine MRI of .\n\n FINDINGS: The sacral nerve roots appear normal bilaterally and there are no\n masses or fluid collections along their courses. However, note is again made\n of asymmetry of the piriformus muscles, left greater than right. However, this\n asymmetry is less than seen on the prior CT of . The left piriformus\n muscle does contain abnormal high T2 signal diffusely, as do all of the\n visualized portions of the gluteus minimus, medius, and maximus muscles on the\n left. There is no abnormal T1 signal in these muscles to suggest hemorrhage or\n atrophy.\n\n Again seen within the left gluteus medius muscle is an ovoid mass-like lesion\n measuring 4.5 x 6.6 cm. It is difficult to compare the size with the prior\n studies as this was not well seen on the prior CT and was only partially\n imaged in a different plane on the prior lumbar spine MRI. This lesion is\n primarily of low T2 signal and intermediate T1 signal. Note is made of several\n prominent linear signal voids wrapping around this lesion, consistent with\n dilated arterial branches.\n\n There are no bone marrow signal abnormalities. The visualized portion of the\n lumbosacral spinal canal appears unremarkable. Sacroiliac joints are normal.\n Limited assessmentof pelvic viscera are unremarkable.\n\n IMPRESSION:\n\n 1. Persistent edema/swelling of left piriformus and gluteus minimus, medius\n and maximus muscles. This may be mildly improved, as the piriformus muscle\n does not appear as large as it did on the CT of .\n\n 2. Persistent mass-like lesion in left gluteus medius muscle. This most likely\n represents an area of myonecrosis with fibrosis, likely related to the\n (Over)\n\n 3:06 PM\n MR PELVIS W/O CONTRAST Clip # \n Reason: please evaluate left sciatic notch for possible outlet compr\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n patient's overdose and rabdomyelysis. Signal characteristics are not\n consistent with an abscess.\n\n 3. F/U MRI in months to confirm resolution of the left gluteal mass\n lesion is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-13 00:00:00.000", "description": "LUNG SCAN", "row_id": 769638, "text": "LUNG SCAN Clip # \n Reason: TACHYCARDIA.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Twenty-three year old man with h/o heroin overdose with rhabdomyolysis\n and anuric renal failure complicated by aspiration pneumonia with intermittent\n chest pain and tachycardia.\n\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate some\n decreased perfusion on the left posterior oblique images that is nonsegmental\n and involves the lateral basal segment and superior segment of the left lower\n lobe.\n\n Perfusion images in the same 8 views show a matched perfusion abnormality in the\n same region.\n\n Chest x-ray shows no evidence of consolidation.\n\n The above findings are consistent with a matched, nonsegmental decrease in\n ventilation/perfusion.\n\n IMPRESSION: Low likelihood of pulmonary embolism. /nkg\n\n\n , M.D.\n , M.D. Approved: TUE 11:31 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2192-08-03 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 768898, "text": " 8:52 PM\n MR W & W/O CONTRAST Clip # \n Reason: r/o abcess or other compressive process\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man h/o IVDU, now with leukocytosis, severe LLE weakness, and EMG\n c/w L5-S1 plexopathy.\n REASON FOR THIS EXAMINATION:\n r/o abcess or other compressive process\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE LUMBAR SPINE.\n\n CLINICAL INFORMATION: Patient with left-sided sacral plexopathy and lower\n extremity weakness and leukocytosis, for further evaluation.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2 axial images\n of the lumbar spine were obtained before gadolinium. T1 sagittal and axial\n images were obtained following gadolinium.\n\n FINDINGS: From T12-L1 to L5-S1, vertebral bodies and discs demonstrate normal\n signal and there is no evidence of disc bulge, disc herniation or spinal\n stenosis. The visualized lumbar vertebral bodies and the sacrum demonstrate\n no evidence of focal signal abnormalities to indicate osteomyelitis or\n diskitis. There is no evidence of epidural collection seen. No abnormal\n intraspinal enhancement is identified.\n\n Note is made of an approximately 5-cm area of T1-hyperintense and T2-\n hypointense signal within the left gluteal region with peripheral irregular\n enhancement. These findings are suspicious for an infected hematoma in the\n left gluteal region. The inferior extent of this collection is not\n visualized. Further evaluation with pelvic CT or MRI is recommended.\n\n The distal spinal cord shows normal signal intensities.\n\n IMPRESSION: No evidence of osteomyelitis or diskitis in the lumbar region. No\n evidence of epidural collection. 5-cm collection indicating infected hematoma\n with abscess in the left gluteal region. Findings are conveyed to Dr. \n at the time of interpretation of this study on at 11:30AM.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 769568, "text": " 1:58 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate/fever source\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with aspiration PNA and ARF secondary to rhabdomyalysis.\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate/fever source\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n HISTORY: Fever.\n\n The heart is normal in size. The lungs are clear. Changes at the left base\n have resolved completely since . Hilar and mediastinal contours are\n normal. There is no effusion or bone destruction.\n\n IMPRESSION: Normal chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-08-09 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 769300, "text": " 1:15 AM\n MR CERVICAL SPINE Clip # \n Reason: PLEASE DO CSPINE AND IN PT WITH UNCLEAR PATTERN OF WE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with sp drug od with rhabdo, arf resolving, with persistant L\n sided weakness\n REASON FOR THIS EXAMINATION:\n PLEASE DO CSPINE AND IN PT WITH UNCLEAR PATTERN OF WEAKNESS, INCLUDING\n UE WEAKNESS AND TREMORS, LE WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVCAL SPINE:\n\n INDICATION: 23 y/o man status post drug overdose with rhabdomyolysis, acute\n renal failure, now with left sided weakness.\n\n COMPARISONS: Reference is made to the patient's head MRI from as\n well as MRI of the lumbar spine from .\n\n TECHNIQUE: Multiplanar MR images of the cervical spine without gadolinium.\n\n FINDINGS: The vertebral bodies of the cervical spine are of normal height and\n alignment. There is no area of signal abnormality within the vertebral\n bodies. There are no focal disc protrusions that cause spinal stenosis. The\n neural foramina are all normal in caliber with the exception of the C4/5\n interspace, where an uncovertebral spur causes minimal foraminal narrowing on\n the right. There is no significant signal abnormality within the spinal cord.\n\n IMPRESSION: No significant central canal or neural foraminal narrowing.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-08-09 00:00:00.000", "description": "MR THORACIC SPINE", "row_id": 769301, "text": " 1:16 AM\n MR THORACIC SPINE Clip # \n Reason: UNCLEAR PATTERN OF WEAKNESS; INCLUDING UE WEAKNESS AND TREMORS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with sp drug od with rhabdo, arf resolving, with persistant L\n sided weakness\n REASON FOR THIS EXAMINATION:\n see c spine request\n ______________________________________________________________________________\n FINAL REPORT\n MR OF THE THORACIC SPINE:\n\n INDICATION: 23 y/o man status post drug overdose, left sided weakness.\n\n COMPARISONS: Reference is made to the patient's cervical spine MRI from ,\n the lumbar spine MRI from , and the head MRI from .\n\n TECHNIQUE: Multiplanar MR images of the thoracic spine from C4-L1 without\n gadolinium.\n\n FINDINGS: The vertebral bodies are of normal height and alignment throughout\n the thoracic spine. There are no areas of abnormal signal intensity present\n within the vertebral bodies of the thoracic spine. There is a mild degree of\n disc dessication at the T5/6 interspace, as well as a very mild right\n paracentral disc protrusion posteriorly which mildly indents the thecal sac.\n There is no evidence of spinal stenosis at this or any other level. There is\n no narrowing of the neural foramen in the thoracic spine. There is no signal\n abnormality demonstrated within the spinal cord throughout its course in the\n thoracic spine.\n\n IMPRESSION: No significant central canal stenosis or narrowing of the neural\n foramina.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768098, "text": " 2:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p line change over wire\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od s/p intubation-follow ards\n\n REASON FOR THIS EXAMINATION:\n s/p line change over wire\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23 y/o man with acute renal failure and rhabdomyelosis. Status post\n intubation. Check status of ARDS and line change over wire.\n\n FINDINGS: A single AP supine chest image is provided. Comparison study dated\n . The right IJ pulmonary artery catheter has been removed. The\n endotracheal tube and the NG tube remain in satisfactory positions. The dense\n consolidations of the left upper lobe and left lower lobe remain essentially\n unchanged since the previous day. There has been slight further resolution of\n the consolidation previously noted in the right lower lobe. The heart and\n pulmonary vessels are unremarkable. No definite pleural effusions are\n identified.\n\n IMPRESSION:\n\n 1. Persistent dense consolidation of the left upper lobe, lingula, and lower\n lobe. Further resolution of consolidation in the right lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2192-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 768642, "text": " 3:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for possible new aspiration pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with arf, rabdo, ? od, now 48 hours s/p\n extubation-being treated for aspiration pna. Now s/p left thoracentesis and\n right IJ line change. continues to spike temps.\n REASON FOR THIS EXAMINATION:\n evaluate for possible new aspiration pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to previous study of .\n\n INDICATION: Line change. Spiking temperatures.\n\n The patient is slightly rotated towards the left. A right internal jugular\n central venous catheter is demonstrated, and probably terminates within the\n superior vena cava. The slightly medial course of the catheter could be\n explained by the leftward patient rotation.\n\n Cardiac and mediastinal contours are stable allowing for rotation. There is\n worsening increased opacity in the left retrocardiac region, and there is also\n worsening but less prominent area of increased opacity in the right lower\n lobe. There is a small left pleural effusion.\n\n IMPRESSION: 1) Central venous catheter likely terminates within the superior\n vena cava, but repeat non-rotated radiograph may be helpful to confirm\n appropriate positioning. No pneumothorax is evident.\n\n 2) Worsening bibasilar lung opacities. This may reflect worsening aspiration\n pneumonia considering history of this process. The left lower lobe is affected\n to a much greater degree than the right.\n\n 3) Small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-05 00:00:00.000", "description": "L US EXTREMITY NONVASCULAR LEFT", "row_id": 769016, "text": " 3:51 PM\n US EXTREMITY NONVASCULAR LEFT Clip # \n Reason: ASSESS ABSCESS VS . HEMATOMA LEFT GLUTEAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man found down now s/p elevated WBC and febrile. Area seen on CT,\n uncertain entity.\n REASON FOR THIS EXAMINATION:\n assess abscess vs hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question abscess in the left gluteal region. Recent MRI\n examination of revealed an oval abnormality in the left gluteus\n maximus muscles, heterogeneous T2 signal and peripheral enhancement of this\n region on T1 post contrast images. The region could represent myonecrosis\n and/or hemorrhage but abscess could not be excluded. Ultrasound exam\n requested for further evaluation.\n\n LEFT LOWER EXTREMITY ULTRASOUND: A focal examination of the left gluteus\n region was performed. Sagittal and axial images reveal no anechoic focal\n fluid collections.\n\n IMPRESSION: No evidence of an abscess in the gluteus muscles on the left.\n\n" }, { "category": "Radiology", "chartdate": "2192-08-05 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 769011, "text": " 1:41 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: abscess vs. hematoma seen on MRI\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man who was found down, had rhabdo with ATN, elevated WBC and\n febrile despite antibiotics.\n REASON FOR THIS EXAMINATION:\n abscess vs. hematoma seen on MRI\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 23-yaer-old man found down with rhabdo, elevated white\n blood cell count, and fever. Left gluteal collection identified on MRI.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained through\n the pelvis without the administration of IV contrast. No IV contrast was\n administered in light of the patient's elevated creatinine.\n\n COMPARISONS: Comparison is made to the patient's MRI of the lumbar spine dated\n .\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The patient's known left gluteal\n collection is not readily apparent on CT. There is enlargement of the left\n gluteal and thigh muscles in comparison with the right, but no discrete fluid\n collection is identified. Note is made of a swollen piriformis muscle on the\n left, which could be obstructing the sciatic notch on the right with resultant\n compression of the nerve bundles in this location. No air is seen within the\n subcutaneous soft tissues and no fluid level is seen in the region of the\n known collection. There is extensive subcutaneous edema. A Foley catheter is\n seen within the collapsed urinary bladder. There is a small amount of free\n fluid in the deep pelvis. The rectum and sigmoid colon appear unremarkable.\n There are bilateral hydroceles. No acute fractures are identified.\n\n IMPRESSION: 1) Patient's known left gluteal collection is not readily apparent\n on CT. It would be helpful to further evaluate this collection with\n ultrasound to determine whether it might be accessible by ultrasound-guided\n drainage.\n 2) Patient's L5-S1 plexopathy may be secondary to swelling of the left\n piriformis muscle.\n\n\n" }, { "category": "Echo", "chartdate": "2192-07-30 00:00:00.000", "description": "Report", "row_id": 72729, "text": "PATIENT/TEST INFORMATION:\nIndication: ?effusion . Murmur.\nHeight: (in) 72\nWeight (lb): 160\nBSA (m2): 1.94 m2\nBP (mm Hg): 123/60\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 16:13\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. No mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size is\nnormal. Right ventricular systolic function is normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are structurally normal. There\nis no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2192-08-20 00:00:00.000", "description": "Report", "row_id": 173639, "text": "Sinus tachycardia\nNormal ECG except for rate\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2192-08-13 00:00:00.000", "description": "Report", "row_id": 173640, "text": "Sinus tachycardia\nST junctional depression is nonspecific\nVoltaage probable normal for age\n\n" }, { "category": "Nursing/other", "chartdate": "2192-07-27 00:00:00.000", "description": "Report", "row_id": 1267493, "text": "\nNursing Progress Note 0700 - 1900\n\nS/O\nNEURO: Propofol turned off for extubation. Pt agitated, trying to d/c ETT. Pt calmed down after extubation, became very anxious, yelling out when incontinent of stool and was quieted with explanation, reassurance and hygeine care.\n\nSpeech mumbled but appropriate. Pt inconsistently follows commands, but follows all which increase his comfort. Moves all extremeities; RUE less so due to swelling and pain at level 1. RUE elevated, warm packs applied, MD notified.\n\nCV: Pulses palp. Right hand blanches, is warm, cap refill < 2 seconds.\n\nRESP: Extubated; initially stridorous with minimal air movement, tachypneic. Albuterol neb given, NT sxn'd, improved airway, but LS remain coarse and diminished. Remains on 50% scoop mask with episodes of tachypnea, diminished cough and somewhat shallow resp. Pt unwilling/unable t comply with coughing/deep breathing.\n\nGI: BM, large and loose, x 2. BS positive, abd soft. C/O hunger.\n\nFEN: Lytes, fluid status stable.\n\nGU: Remains oliguric.\n\nSKIN: Pressure areas remain pink without breakdown. Skin care given, position changes done.\n\n\nPSYCH: 1:1 suicide precautions maintained at all times.\n\nA/P\nContinue pulmonary toilet as appropriate.\nMoniter FEN.\nContinue 1:1 suicide precautions.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-28 00:00:00.000", "description": "Report", "row_id": 1267494, "text": "NURSING PROGRESS NOTE 7P-7A\nREPORT RECEIVED AT 1900. PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR FUNCTIONING. 1:1 SITTER AT BEDSIDE.\n\nNEURO: PT. IS LETHARGIC BUT RESPONDS APPOPRIATELY. ORIENTED X 3. FOLLOWS COMMANDS AND EXPRESSES APPROPRIATE NEEDS SUCH AS GOING TO THE BATHROOM. NEEDS CONSTANT REASSURANCE FOR OCCASSIONAL ANXIETY EPISODES. PT. IS DIFFICULT TO UNDERSTAND AT TIMES DUE TO SOFT VOICE AND HOARSE VOICE, SPEECH IS ALSO SLURRED- IMPROVED AS SHIFT HAS PASSED. MOVES RIGHT SIDE WITHOUT DIFFICULTY- ABLE TO MOVE LEFT SIDE BUT IS WEAKER. PERLA. NO SEIZURE ACTIVITY NOTED. LOW GRADE TEMP-100.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NO GALLOPS, MURMURS OR RUBS AUSCULTATED. NO COMPLAINTS OF CHEST PAIN. PT IS HR 90-125 WITH NO SIGNS OF ECTOPY. SBP > OR = TO 100. ALINE TO LEFT RADIAL RECALIBRATED AND REZEROED DURING SHIFT, SECURE AND PATENT. AT TIMES WAVEFORM IS DAMPENED. PT. TOLERATED BANDAGE CHANGE WITHOUT DIFFICULTY. BILATERAL RADIAL AND DORSALIS PEDIS PULSES ARE EASILY PALPABLE. NO SIGNS OF JVD NOTED. CVL TO RIGHT IJ IS SECURE AND PATENT WITH BLOOD DRAWBACK AND FLUSHES WITHOUT DIFFICULTY.\n\nRR: PT INITIALLY ON 50% SCOOP MASK, HAVE BEEN ABLE TO WEAN TO 4 LITERS NASAL CANNULA WITHOUT DIFFICULTY. SP02 > OR = TO 96%. BBS= ESSENTIALLY CLEAR, SOME COARSENESS TO LEFT SIDE THAT RESOLVES WITH NT SUCTIONING. BILATERAL CHEST EXPANSION NOTED. PT. HAS WEAK COUGH EFFORT. SHALLOW BREATHER- RR 20-30 DEPENDENT ON AGITATION LEVEL. PT EDUCATED ON DEEP BREATH AND COUGHING HOWEVER PT HAS NOT BEEN ABLE TO DO THIS.\n\nGI: ABDOMEN IS SOFT, NON DISTENDED AND NONTENDER TO PALPATION. BS X 4 QUADRANTS. PT IS PASSING FLATUS AND HAD LARGE, SOFT-LOOSE BROWN-BLUE BM X 5 DURING THE SHIFT. HAS BEEN ABLE TO TAKE PO MEDS WITHOUT DIFFICULTY AND TOLERATING SIPS OF WATER WITH PILLS WITHOUT ANY COMPLAINTS OF NAUSEA, NO VOMITING.\n\nGU: INDWELLING FOLEY CATHETER SECURE AND PATENT. PT AVERAGES 10CC/HR OF AMBER CLEAR URINE. TEAM IS AWARE OF PT BEING ANURIC.\n\nINTEG: PT HAS SOME REDDNESS TO BUTTOCKS DUE TO HAVING TO BE CLEANED OFTEN- HAVE BEEN TURNING AND REPOSITIONING Q 2 HOURS FOR PREVENTATIVE MEASURES. PINK-RED LESIONS TO BILATERAL ANKLES AND TO LEFT BUTTOCK.\nPT ALSO HAS SWELLING, REDNESS AND HEAT TO LEFT UPPER EXTREMITY ALTHOUGH HE HAS A PALPABLE RADIAL PULSE AND CAP REFILL > THAN 3. DR. MADE AWARE- WILL DO DOPPLER STUDIES TO RULE OUT A VENOUS CLOT. ELEVATION OF EXTREMETY AND WARM COMPRESSES FOR PATIENT'S COMFORT. PT. HAS BEEN COMPLAINING OF PAIN TO THE AREA AND HAS REQUIRED MEDICATION WITH HIS PERCOCET 2 TABLETS Q 4 HOURS PO AS NEEDED FOR PAIN.\n\nID: SPUTUM, URINE CULTURES SENT. PT. RECEIVED HIS DOSE OF LEVOFLOX TODAY (Q 48 HOUR DOSES).\n\nSOCIAL: FAMILY IN TO VISIT. AWARE OF PT'S CONDITION.\n\nPLAN: CONTINUE TO MONITOR PULMONARY STATUS AND AGGRESSIVE PULMONARY TOILETING. DOPPLER STUDIES TO LEFT UPPER EXTREMITY. CONTINUE WITH 1:1 SITTER AND SUICIDE PRECAUTIONS. PSYCH EVAL. WILL CONTINUE TO MONITOR CLOSELY AND TREAT AS NEEDED. PLEASE S\n" }, { "category": "Nursing/other", "chartdate": "2192-07-28 00:00:00.000", "description": "Report", "row_id": 1267495, "text": "NURSING PROGRESS NOTE 7P-7A\n(Continued)\nEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2192-07-28 00:00:00.000", "description": "Report", "row_id": 1267496, "text": "Nursing note for Micu B 0700-1900\n\nNeuro: Pt is very lethargic, pt did not answer questions when asked, but does follow commands. Can not track with his eyes. Able to move right leg and unable to move left leg on command. Pt found at times just starring at the wall. Pearl 3mm but sluggish. Ct scan done this afternoon, per team ct negative. Pt is not on any narcs. When turing pt, he is like a rag doll, does not move at all.\n\nResp: Started on 4 liters via nc, weened down to 2 liters, sat's in the high 90's. Pt sxned q3-4 hrs for thick white secretions. bs clear.\n\nCV: Pt's hr 100's st no ectopy noted. Pt has 2+ pedal and ankle edema up to calves, bilaterally, positive pedal pulses. left arm is swollen. ultrasound done at bedside this afternoon, negative exam per tech. aline dressing changed damped and at times it is sharp, very positional.\n\nHD: had hd this am, took off 2 kg, well\n\nGU/GI: Ng tube placed in left nares # 16 by intern, to lws at this time at 1800 will start tf at 10 cc per hr.\nPt is to start on tpn, team has not been in to change lumen of IJ\npt has had multiple soft stool, guiac negative. Urine is very dark yellow to amber color, 0-10 cc / hr.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2192-07-28 00:00:00.000", "description": "Report", "row_id": 1267497, "text": "Adden for 0700-1900\nMicu B\nCxr done for placement of ngt in place . tf up at 1800\n\nNeuro consult in at 1800, family in at bedside, updated and informed.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-29 00:00:00.000", "description": "Report", "row_id": 1267498, "text": "NURSING PROGRESS NOTE 7P-7A\nREPORT RECEIVED AT 1900. PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR FUNCTIONING.\n\nNEURO: FEBRILE WITH TMAX OF 100. RESOLVED. PT HAD MRI OF HEAD DONE AT 2100 TO RULE OUT STROKE AS PER NEURO CONSULT. PT. TOLERATED PROCEDURE WITHOUT DIFFICULTY AND WAS TRANSPORTED BY COWORKER AND RN WITHOUT ANY UNTOWARD INCIDENCES. PERLA. PT HAS HAD 3-5MM PUPILS THAT HAVE HAD BRISK REACTIONS. INITIALLY, RECEIVED PT AS LETHARGIC AND VERY SLEEPY, WOULD NOT OBEY COMMANDS, AS NIGHT HAS , PT HAS BEEN INTERACTIVE WITH RN. WILL EXPRESS NEEDS APPROPRIATELY ALTHOUGH SPEECH IS STILL DIFFICULT TO UNDERSTAND. ABLE TO ANSWER YES/NO QUESTIONS WITHOUT DIFFICULTY. ORIENTED TO PLACE AND SELF. 2400 ASSESSMENT WAS CONCLUSIVE FOR PT. OBEYING COMMANDS, HOWEVER WAS EXTREMELY DIAPHORETIC AND SHIVERING. DR. MADE AWARE AND AS MD ORDER 2 MG OF IV ATIVAN GIVEN. PT REACTED VERY WELL TO THIS, TREMORS AND DIAPHORETIC STATE SUBSIDED. POSSIBLE WITHDRAWAL FROM BENZOS- HAS PRN ORDER FOR .5-2MG OF ATIVAN IV AS NEEDED FOR THESE SYMPTOMS. NO SEIZURE ACTIVITY NOTED. PT HAS SLEPT COMFORTABLE THROUGH THE NIGHT. AROUSABLE TO VERBAL STIMULI. PT WILL MOVE EXTREMETIES TO THE RIGHT SIDE WITHOUT DIFFICULTY BUT WILL NOT MOVE HIS RIGHT LOWER EXTREMITY. TEAM IS AWARE. WILL OCCASSIONALLY MOVE HIS RIGHT UPPER EXTREMETY BUT IS OBVIOUSLY WEAKER AND HAS DISCOMFORT WITH HIS ATTEMPTS.\n\nRR: PT. HAS REMAINED ON 2L NC WITHOUT ANY RESPIRATORY DISTRESS NOTED. BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER AND LOWER LOBES, AT 2230 HAD SOME COARSE LUNG SOUNDS WHICH WAS RESOLVED WITH NT SUCTION. PT HAS WEAK COUGH REFLEX, ALTHOUGH HAS BEEN ENCOURAGED- IS NOT ABLE TO DO DEEP BREATHING AND COUGHING EXERCISES- IN VIEW OF THIS, HAVE MONITORED RESPIRATORY STATUS CLOSELY BUT HAVE HAD NO UNTOWARD INCIDENCE. BILATERAL CHEST EXPANSION NOTED. SP02 95-100%. RR 15-20.\n\nCV: PT HAS BEEN IN NSR WITH NO SIGNS OF ECTOPY, SBP > OR = TO 100 WITH NO SYMPTOMATIC HYPO OR HYPERTENSIVE CRISIS. LEFT RADIAL ALINE IS SECURE AND PATENT, RECALIBRATED AND ZEROED DURING THE SHIFT. TRANSDUCER SET CHANGED. PT. TOLERATED WITHOUT ANY DIFFICULTY. S1 AND S2 AS PER AUSCULTATION. NO RUBS, GALLOPS OR MURMURS AUSCULTATED. PT DENIES ANY CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL RADIAL AND DORSALIS PEDIS. NO SIGNS OF JVD NOTED. RIGHT IJ TL CVL IS SECURE AND PATENT, FLUSHES AND DRAWS BACK WITHOUT DIFFICULTY.\n\nGI: ABDOMEN IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. NGT TO LEFT NARE IS SECURE AND PATENT. POSITIVE PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC OR AIR. PT HAS HAD NO GASTRIC RESIDUALS . HAS TOLERATED TF OF NEPRO WITHOUT DIFFICULTY. RATE INCREASE TO 20CC/HR FROM 10CC/HR AT 0600 AS ORDERED. DUE TO ASPIRATION PRECAUTIONS, BLUE DYE ADDED TO TUBE FEED AS PRECAUTIONARY MEASURE. PT HAS HAD ONE LARGE, BROWN, LOOSE STOOL. RECEIVED HIS LAXATIVES AS ORDERED.\n\nGU: PT ANURIC. UOP IS 5-10CC AN HOUR. AMBER CLEAR URINE AS PER INDWELLING URETHRAL FOLEY CATHETER.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-31 00:00:00.000", "description": "Report", "row_id": 1267506, "text": "FOCUS; ADDENDUM\nACTIVITY- OOB TO CHAIR WITH ASSIST OF PT. WILL NEED ASSIST OF 2 TO GET BACK TO BED.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-24 00:00:00.000", "description": "Report", "row_id": 1267487, "text": "Neuro: Pt remains sedated. pt will respond to pain. pt is currently on a Fentanyl gtt @ 150mcg/hr and Adivan gtt @ 5 mg/hr. sedation being weaned for possible extubation in the near future. pt pupils are 3mm and will open eyes to stimuli.\n\nCard: pt last Swan readings are PAD 20, PWP 17, CO 7.7, CI 4.38, SVR 925. PA changed over a wire to a R IJ TLC, all port flush, and have blood return, x-ray taken and checked. PT BP is currently 108/63 MAP 75. Pt remains on Dopamine gtt @ 2mcg, weaning dopa gtt as tolerated.\n\nResp: py remains on vent AC/40/600/14/10. pt sao2 is 98-100 on curent settings. Last ABG IS 7.27/36/112/17. PT REQUIRES Q 4 HOUR sutioning for mod amounts of tan secreations. Pt has had no vent changes throught the day.\n\nGI/GU: Pt BUN/CR is 53/5.9. Pt had HD today for a net loss of 2200cc fo fluid. pt will not get HD tomorrow, but is planned to get on thursday. PT UO is poor <10 cc/hr. Pt had Nepro started @ 10/cc. Reglan also started.\n\nSkin: pt has multiple red on leg, and backside, ? if pressure ulcer VS skin abnormality.\n\nPlan: Wean dopa gtt as tolerated, and slowly wean sedation for possible vent wean in AM.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-25 00:00:00.000", "description": "Report", "row_id": 1267488, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT RECEIVED ON ATIVAN 5MG/HR AND FENTANYL 150MCG/HR. PT RESPONDS TO PAIN STIMULI, OPENS EYES AND WILL ATTEMPT TO LIFT HEAD AND CHEST. NOT ABLE TO FOLLOW COMMANDS. WILL MOVE ALL EXTREMITIES. PLAN IS TO WEAN SEDATION. AT 0500 FENTANYL 125MCG/HR AND ATIVAN 4MG/HR.\n\nRESP: NO VENT CHANGES MADE. PT CONTINUES ON AC 600X14 PEEP10 40%. PT WILL BREATH 1-2BPM OVER. O2 SATS 99-100%. AM ABG 7.32/30/156/-. LS COARSE THROUGH OUT. SUCTIONED X4 FOR SMALL AMT THICK BROWN/BLOOD TINGED SECRETIONS.\n\nCV: HR NSR 70-80'S, NO ECTOPY. PT RECEIVED ON DOPAMINE GTT, ABLE TO WEAN OFF AT 2400. SBP 90-110'S. GENERALIZED +1 EDEMA.\n\nGI/GU: ABD SOFT, HYPO BS EARLY IN SHIFT, AT PRESENT TIME NO BS. NO BM. PT CONTINUES ON REGLAN. TF CONTINUE VIA OGT INCREASED TO 20CC/HR AT 0500. RESIDUALS ~50CC. U/O >10CC/HR CLEAR YELLOW.\n\nID: PT CONTINUES ON OXACILLIAN AND FLAGYL. PT DUE FOR DOSE OF LEVOFLOXACIN THIS AM. MAX TEMP 99.1. BC FROM PENDING. URINE AND SPUTUM FROM NEGATIVE.\n\nACCESS: TLC SITE EARLY IN SHIFT RED AND SLIGHTLY SWOLLEN, SWELLING HAS GONE DOWN. DRESSING CHANGED. PIV IN LEFT UPPER ARM D/C'D DUE RED AND RED STREAK UP ARM. IV WAS CLAMPED OFF AT TIME. WILL CONTINUE TO MONITOR SITE. PT HAS 2 PIV'S IN RIGHT ARM, RR A-LINE AND RIGHT FEM DIALYSIS CATH.\n\nSKIN: PT CONTINUES TO HAVE RED RASH PATCHES, NON RAISED, ON RLL, LEFT ANKLE, LEFT INNER KNEE. NEW PATCH NOTED ON RIGHT UPPER THIGH ~SIZE OF . ALL PATCHES OUTLINE IN PEN TO MONITOR ANY GROWTH. DR. AWARE OF NEW PATCH.\n\nDISPO: PLAN IS TO CONTINUE TO WEAN SEDATION IN ATTEMPT TO WEAN VENT SETTINGS AS PT WAKES UP. WILL MONITOR TF RESIDUALS. PT IS TO BE DIALYZED ON THURSDAY. TEAM IS CONSIDERING DERM CONSULT DUE TO INCREASE IN RASHES. PT FAMILY IN LAST NIGHT TO VISIT. WOULD LIKE TO SPEAK WITH DR TODAY FOR UPDATE AND PLAN. ? FAMILY . PARENTS WILL CALL THIS AM TO LET US KNOW WHEN THEY WILL BE IN. PT REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-25 00:00:00.000", "description": "Report", "row_id": 1267489, "text": "MICU NPN 7A-7P\nNeuro: Pt. remains sedated on multiple drugs. Wean of both drugs currently in progress: Ativan @ 2mg/hr and Fentanyl @ 50mcg/hr. PERRLA, not generally following commands, does turn head towards voices, occasionally moves hands and tries to sit up (easily calms with someone telling him where he is). One episode @ ~ 1300 today wherein pt. opened eyes, BP and HR increased (HR into 150's), and he squeezed his hand in response to command. No repeats of this episode over the course of the shift.\n\nResp: Pt. remains intubated and vented. Current settings are A/C 600 x 14 FiO2 40% PEEP 8 (decreased from 10 @ noon), FiO2 97-100%. Occasionally overbreathing vent by 1-2 breaths. Lungs coarse T/O, sxn'd x 3 for thick tan secretions. Chest CT from yesterday showed increase in B pleural effusions, consolidation per Dr. . Plan is to attempt further wean of vent support when pt. is awake enough to breathe effectively. Please continue to titrate down sedation with this goal.\n\nCV: BP 90-120/50-70 (SBP ^ 160's with agitation), stable off of Dopa. HR NSR 70-80's. + generalized edema.\n\nGI: Bowel sounds considered absent for 1st 8 hrs. of shift. Team aware; more aggressive bowel regimen ordered (Colace, Senna and MOM prn ordered in addition to Reglan). At 1600, hypoactive BS appreciated by RN in RUQ, + smears of stool found upon turning. TF changed from Nepro to Nepro with Promod @ 1700; currently @ goal rate of 35 cc/hr. Residuals from 40-75cc today; decreased from 75 @ noon to 50 @ 1600. Please continue to monitor closely.\n\nGU: Foley patent, now draining ~5cc/hr clear yellow urine. Team aware. Plan is currently for dialysis tomorrow.\n\nID: Sputum cx from came back + MRSA. Oxacillin D/, pt. started on Vanco @ 1600; plan is to check a Vanco level in the AM and dose appropriately. Pt. remains on Flagyl and Levaquin. He remains afebrile today.\n\nSkin: Multiple red rashy areas on legs, no more appreciated today. Dermatology in to see pt.; per attending, the sites are in fact pressure ulcers, and should resolve within ~ 1 wk. We are to re-consult Derm if the rashes become more numerous or begin to change in character. Pt. remains on Theradyne bed.\n\nSocial: Pt.'s parents in to see him today; updated on plan of care by RN and by Dr. . Very pleasant and appropriately concerned.\n\nSee CareVue for further details.\n" }, { "category": "Nursing/other", "chartdate": "2192-08-01 00:00:00.000", "description": "Report", "row_id": 1267507, "text": "MICU NPN 1900-0700:\n\nNEURO: Awake & alert . Oriented x3. speech is clearer. Is able to verbalize all needs & is cooperative in care. Continued left leg weakness noted. Encouraged ROM & exercise. Is able to move in bed & is progressivley stronger this am. Slept off & on. IV Ativan given @ 0445 per request for rest. Denies suicidal ideation. 1:1 sitter @ BS.\n\nCV: Monitor NSR 70-90 no ectopy. Hemodynamically stable. SBP 120-150's. Receives Clonidine TID. Trace edema noted left arm, hip & leg. Peripheral pulses all palpale. TLC RIJ intact with NS @ KVO. Site clear. All ports with good blood return noted. Left radial arterial line intact with good waveform noted. Aline 30-40 points greater than NIBP. Denies pain or discomfort.\n\nRESP: On room air. Lungs clear throughout. Sats high 90's. Denies SOB. RR 16-20. Contact precautions for MRSA of sputum. Pt. is not expectorating\n\nGI: No diarrhea stools noted this shift. TF Nepro with Promod @ 35 cc/hr goal to NG. Scant residual. Tolerates well. NPO. Expresses thirst & hunger often. ST to eval & give recommendations.\n\nGU: Foley cath with 0-10 cc/hr. CRT 9.2. AM labs pending. For possible dialysis this am, however requires insertion of permacath prio to.\n\nID: TMAX 101. Currently on Flagyl,Levo. Received Vanco x1 .\n\nPLAN: Awaiting bed on 4 or 5 as is called out. Continue monitor of lytes, WBC, & culture results ( negative thus far). Possible inserion of Permacath with possible dialysis. Continue suicide precautions wiht 1:1 sitter.\n\n" }, { "category": "Nursing/other", "chartdate": "2192-07-26 00:00:00.000", "description": "Report", "row_id": 1267490, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT CONTINUES ON SEDATION CURRENTLY ON 1MG/HR ATIVAN AND 25MCG/HR FENTANYL. PT WILL OPEN EYES TO PAIN STIMULI. PT WILL MOVE ALL EXTREMITIES WHEN STIMULATED PT CARE. NOT ABLE TO FOLLOW COMMANDS.\n\nRESP: NO VENT CHANGES MADE OVERNIGHT. REMAINS AT AC 600X14 PEEP 8 AT 40%. AM ABG 7.28/36/166/-. O2 SATS 99-100%. PT NOT OVERBREATHING VENT. PLAN IS FOR WEANING TRIAL THIS AM. SUCTIONED FOR SMALL AMT TAN THICK SPUTUM Q4HRS.\n\nCV: HR SINUS 80'S. NO ECTOPY. SBP 110-130'S. GENERALIZED +1 EDEMA.\n\nGI/GU: ABD SOFT, HYPO BS, +SMALL AMT STOOL. TF AT GAOL 35CC/HR. RESIDUALS 45-100CC. FOLEY INTACT DRAINING CLEAR YELLOW URINE >15CC/HR.\n\nID: VANCO LEVEL THIS AM PENDING. CONTINUE ON LEVOFLOXACIN Q48HRS. MAX TEMP 100.2, AM WBC PENDING.\n\nSKIN: NO CHANGES IN RASHES/PRESSURE SORES ON BIL LOWER EXTREMITIES. WILL CONTINUE TO MONITIOR.\n\nDISPO: PT IS TO HAVE DIALYSIS TODAY. PLAN IS TO WEAN SEDATION IN ATTEMPT TO WEAN VENT SETTINGS. PT IS TO HAVE WEANING TRIAL THIS AM. FAMILY IN TO VISIT IN EVENING, WILL BE BACK THIS AM. PT REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-26 00:00:00.000", "description": "Report", "row_id": 1267491, "text": "NEURO: OPENS EYES TO VOICE AND FOLLOWS SIMPLE COMMANDS. +PERRLA NOTED. PURPOSEFUL MOVEMENT OF EXTREMITIES X4 NOTED. ATIVAN AND FENTALY GTT'S OFF AS ORDERED.\nCV: MONITOR SHOWS NSR WITH NO ECTOPY.\nRESP: LS COARSE THROUGHOUT. SXN THICK TAN SECRETIONS VIA ETT. PT PLACED ON PS 5/5 ONCE SEDATION OFF AND ABG OBTAINED. RR 15-22. PLAN TO EXTUBATE THIS EVE ONCE MORE AWAKE.\nGI: ABD SOFT AND NONTENDER. +BS NOTED. INC LIQUID STOOL SM X2. TF'S OFF FOR EXTUBATION.\nGU: FOLEY INTACT AND PATENT DRAINING SM AMTS AMBER COLORED URINE WITHOUT SEDIMENTATION NOTED. PT RECEIVED HD TODAY AND TOLERATED WELL.\nSKIN: PRESURE AREAS TO BLE REDDENED AND INTACT WITH NO DRAINAGE NOTED.\nI-D: LOW GRADE TEMP THROUGHOUT SHIFT. REMAINS ON FLAGYL AND LEVO.\nPSY-SOC: FAMILY IN TO VISIT AND UPDATED ON STATUS AND PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-27 00:00:00.000", "description": "Report", "row_id": 1267492, "text": "NURSING PROGRESS NOTE 7P-7A\nREPORT RECEIVED AT 1900. AT THAT TIME PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING.\n\nNEURO: PT IS CURRENTLY ON PROPOFOL DRIP THAT IS BEING TITRATED FOR SEDATION. FOR NEURO ASSESSMENT PURPOSES, PROPOFOL DRIP TURNED OFF, PT WILL AROUSE TO VOICE AND NOD APPROPRIATELY TO YES/NO QUESTIONS, WILL OCCASSIONALLY OBEY COMMANDS. GETS ANXIOUS WITHOUT PROPOFOL. MAE X 4 WITH PURPOSE. PERLA. NO SEIZURE ACTIVITY NOTED. PT. HAS HAD TO REMAIN IN BILATERAL UPPER WRIST RESTRAINTS DUE TO ANXIETY AND INTERFERING WITH MEDICAL DEVICES. CONSTANT REASSURANCE AND ORIENTATION GIVEN BY RN.\n\nCV: PT HAS REMAINED IN NSR-ST WITH NO SIGNS OF ECTOPY. HR 90-110. SBP > OR = TO 100 WITH NO SYMPTOMATIC HYPER OR HYPOTENSIVE CRISIS NOTED ASIDE FROM SLIGHT ELEVATION OF SBP TO 160-170'S WHEN AGITATED. THIS IS REMEDIED WITH ORIENTATION AND TITRATION OF PROPOFOL. S1 AND S2 AS PER AUSCULTATION. NO RUBS, GALLOPS OR MURMURS AUSCULTATED. PT. DENIES ANY CHEST PAIN. NO SIGNS OF JVD NOTED. BILATERAL RADIAL AND DORSALIS PEDIS PULSES ARE PALPABLE. LEFT RADIAL A- RECALIBRATED ADN ZEROED DURING THE SHIFT- REMAINS SECURE AND PATENT.\n\nRR: PT. HAS HAD NO VENT CHANGES. REMAINS ON CPAP AND PS 40%FI02, 5 PEEP, 5 PS WITH TV 400'S. PLAN TO EXTUBATE THIS MORNING WITH 1:1 SITTER AT BEDSIDE DUE TO SUICIDE PRECAUTIONS. BBS= VERY COARSE THROUGHOUT BILATERAL UPPER AND LOWER LOBES. PT. HAS # 8 OETT THAT IS SECURED AND PATENT AT 24CM TO THE LIP. BILATERAL CHEST EXPANSION NOTED. PT HAS HAD TO BE SUCTIONED Q 2 HOURS FOR SMALL TO MODERATE AMOUNTS OF THICK, TAN SECRETIONS.\n\nGI: PT HAS SOFT ABDOMEN, NON-DISTENDED, BS X 4 QUADRANTS. OGT IN POSITIVE PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR. TUBE FEEDS HAVE BEEN LEFT OFF THIS PM AS PER ORDER OF DR. IN ANTICIPATION OF EXTUBATION TOMORROW. PT HAD SMALL SEMIFROMED BROWN STOOL TONIGHT.\n\nGU: PT HAS VERY MINIMAL OUTPUT. DR. IS AWARE. UOP IS 5-6 CC/HR. PT REMAINS WITH INDWELLING FOLEY CATHETER THAT IS SECURE AND PATENT IWHT AMBER CLEAR URINE NOTED.\n\nINTEG: PT HAS NO SIGNS OF BREAKDOWN OR OPEN LESIONS BUT HAS RED SPOTS TO BUTTOCKS AND BILATERAL ANKLES WHICH HE HAD PRESENTED WITH. PT. REMAINS OF AIR MATTRESS WITH ROTATING FUNCTIONS AND IS BEING TURNED FROM SIDE TO SIDE Q 2 HOURS.\n\nPLAN: EXTUBATE. 1:1 SITTER. CONTINUE WITH ANTIBIOTICS, REPLETE ELECTROLYTES AS NEEDED. MAINTAIN SAFE ENVIRONMENT. WILL CONTINUE TO MONITOR AND TREAT AS NEEDED. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-23 00:00:00.000", "description": "Report", "row_id": 1267485, "text": "NEURO PT OPENING EYES SLIGHTLY AT 0430 WITH ORAL SUCTIONING. PT WITHOUT FOLLOWING COMMANDS. PT AFEBRILE DIFFICULTY WITH SWAN CORE TEMP DURING NIGHT ORAL TEMP COMPARED ON VS GRID. WBC THIS 13.3 DOWN FROM 13.6 THIS AM.\nCARDIAC HR 80-90 BP KEEPING MAP >65. DOPA GTT AT 5MCG THIS AM WILL CONTINUE TO WEAN. PA'S 30'S/18-20 PCWP 11 CVP 10. NS AT 100/HR X 3L TO KEEP PCWP 15-18 CVP 13-15. PT WAS CLOSE TO RANGE WHEN AT 200/HR NEED SWITCHED BACK. CO PER FLOW DONE VIA FICK R/T CORE TEMP DIFF. SVR DOWN R/T ? DOPA WEAN. PTT 33.4 TO 54 TODAY INR 1.6 TO 1.8 TOD. MG 1.1 DURING NIGHT REPLACED WITH 3G NOW 1.7. K 4.3! PENDING CK THIS AM. PT WITH ? S3. PT WT 63.5 TOD 72.8! SCLERAL AND GEN EDEMA\nRR PT AC 40% PEEP 10 RR 14 OVER NIGHT. WELL. 7.34/31/74/17 PT STILL WITH PINK FROTHY SPUTUM. LUNG AUSC. DIMINISHED L SIDED CRACKLES UNALBE TO HEAR THIS AM. PT NOT TURNS ON R SIDE DECR. BP AND O2SAT. IS TRYADINE BED ROTATION S TO S 15 DEG.\nGI PT WITH OGT LIS HEME + TRACE ON PROTONIX. ? START NUTRITION ALBUMIN 2.4\nGU BUN/CREAT 37/2.7 TOD 41/3.9 URINE CL YELL. PT WITH 5-15CC/HR.\nSKIN PT STILL WITH REDENED AREAS ON LEGS UNCHANGED BUTTOCKS AREA SEEMS LESS PINK TODAY.\nSOCIAL PT'S SUBSTANCE/MEDS FROM HOME GIVEN TO PHARMACY () FAMILY AT BS TONIGHT X2 GIVEN UPDATE DID NOT FEEL THEY NEEDED TO SPEAK WITH MD. GIVEN EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-30 00:00:00.000", "description": "Report", "row_id": 1267501, "text": "NURSING PROGRESS NOTE 7P-7A\nREPORT RECEIVED AT 1900. PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR ARE FUNCTIONING. 1:1 AT BEDSIDE.\n\nNEURO: AT BEGINNING OF SHIFT PT. INITIALLY VERY SEDATED. WOULD AROUSE TO PAINFUL STIMULI BUT WOULD NOT INTERACT. SLEEPING. PERLA AT THAT TIME. LIMITED MOVEMENT NOTED TO LEFT UPPER AND LOWER EXTREMETIES. DURING 2400 ASSESSMENT, PT. WOKE UP AND BEGAN CONVERSING APPROPRIATELY, AWARE OF WHERE HE WAS AND RN'S NAME, ABLE TO ASK FOR WATER AND POSITION CHANGES, SPECIFICALLY ASKED FOR MOUTH CARE AND BABY POWDER TO SORE BUTTOCKS, SPECIFICALLY ASKED FOR A SLEEPING PILL. -LUCID AND COHERENT. SPEECH IS STILL SLURRED AND IS DIFFICULT TO UNDERSTAND AT TIMES. FROM 2400 PT HAS BEEN COMMUNICATING NEEDS AND FOLLWING COMMANDS. STILL WEAKER TO LEFT SIDE AS OPPOSSED TO RIGHT SIDE BUT IS ABLE TO MOVE LEFT UPPER AND LOWER EXTREMITY WITH SOME EFFORT ON BED. STILL NOT ABLE TO LIFT AND HOLD. PERLA AT THIS TIME. NO SEIZURE ACTIVITY NOTED. AT 0200, MEDICATED WITH 2MG OF ATIVAN FOR DIAPHORESIS, TREMORS AND INCREASED BLOOD PRESSURE. RESOLVED AFTER 2MG OF ATIVAN IV GIVEN.\n\nCV: PT HAS REMAINED IN NSR WITH HR 70-90'S WITH NO SIGNS OF ECTOPY. SBP > OR = TO 110 AND ABOVE. LEFT RADIAL ALINE IS SECURE AND PATENT. FLUSHES WITHOUT DIFFICULTY, SHARP WAVEFORM IS NOTED. RECALIBRATED AND REZEROED DURING SHIFT. S1 AND S2 AS PER AUSCULTATION. NO RUBS, MURMURS OR GALLOPS AUSCULTATED. PT. DENIES ANY CHEST PAIN. BILATERAL UPPER AND LOWER RADIAL AND DORSALIS PEDIS PULSES ARE EASILY PALPABLE. CAP REFILL TO ALL EXTREMETIES IS < 3. NO SIGNS OF JVD NOTED. LEFT IJ CVL CHANGED OVER GUIDWIRE TODAY, SECURE AND PATENT, FLUSHES AND DRAWS BACK WITHOUT DIFFICULTY.\n\nRR: PT REMAINS ON 2 L NC. RR 15-20. SP02 95-100%. BBS= ESSENTIALLY CLEAR. PT WILL COUGH WHEN INSTRUCTED TO- GOOD COUGH EFFORT, STRONGER THEN PAST THREE NIGHTS. HAVE ENCOURAGED COUGH AND DEEP BREATHING EXERCISES. PT IS COMPLIANT WHEN RN IS WORKING WITH HIM, OTHERWISE WILL NOT DO SO ON HIS OWN. BILATERAL CHEST EXPANSION NOTED. NO SECRETIONS EXPECTORATED.\n\nGI: ABDOMEN IS SOFT AND NON-DISTENDED, NON-TENDER TO PALPATION. BS X 4 QUADRANTS. NG TUBE TO LEFT NARE IS SECURE AND PATENT WITH POSITIVE PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC OF AIR. PT HAS HAD 2 BM- BLUE TINGED FROM DYE IN TF, BROWNISH AND SOFT. PT HAS BEEN PASSING FLATUS WITHOUT DIFFICULTY. NEPRO IS NOW AT GOAL RATE OF 40CC- NO RESIDUALS. BLUE DYE DUE TO ASPIRATION PRECAUTIONS.\n\nGU: ANURIC. 5-10CC OF CLEAR AMBER URINE NOTED. DIALYSIS TODAY.\n\nINTEG: LESIONS TO BILATERAL ANKLES AND BUTTOCKS HAVE NOT CHANGED. PT HAS REDNESS TO BACK AND SCROTUM- AGGRESSIVELY BEEN TURNING PATIENT TO PREVENT ANY FURTHER BREAKDOWN AS WELL AS SKIN BARRIER PROTECTIVE OINTMENT OVER AREA. STILL HAS EDEMA AND WARMTH TO BILATERAL UPPER AND LOWER LEFT EXTREMETIES EXTENDING TO LEFT TRUNK WITH PITTING EDEMA NOTED. TEAM IS AWARE.\n\nPLAN: CONTINUE TO MONITOR CLOSELY, TREAT ELECTROLYTES AS NEEDED AFTER DIALYSIS. PLEASE SEE FLOW SHEET AS NEEDED FOR ADD\n" }, { "category": "Nursing/other", "chartdate": "2192-07-30 00:00:00.000", "description": "Report", "row_id": 1267502, "text": "NURSING PROGRESS NOTE 7P-7A\n(Continued)\nITIONAL INFORMATION. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-24 00:00:00.000", "description": "Report", "row_id": 1267486, "text": "Neuro pt opening eyes resp to light being turned on. pt nodding head to questions and following commands. Pt also trying to sit up in bed so sedation increased. Pt afebrile. WBC yest13.3 today 11.2\nCard. Pt core temp not working on swan 0 co ordered. HR stable 80 pcwp 11-14 tonight cvp 11-15. pa's 38-42/20's Pt was to be kept at 5mcg of dopa r/t incr renal perfusion yet bp hitting 140's pas 45. Dopa weaned to 2.5 yet UO dropped to 0. Pt back up to 5mcg so far. MD aware. Pt given 1amp cagluc during night ion ca 1.05 Ca this am 7.2 md aware. PO4 4.9 and acidosis increasing. pt to be dialyzed today. also may change swan to ?QUAD central line today ? need for TPN KEEP ONE LINE OPEN & clean.\nRR Pt on AC 40% TV 600 PEEP 10 RR 14. ABG this am 7.29/32/88/16 met acid to be corrected with dialysis today. Pt coughing tonight..new sx for pink frothy sputum. not overbreathing vent. sats seen at 99% at one point during night. Lung ausc changed this am to Crackles on L side (dependant side.)R remains decreased and clear. Pt tolerating tryadine bed at 20 degr rotation tonight.\nGI Pt with very hypoactive BS bilious drainage will eval for possible tube feedings today to incr albumin. day #3 w/o nutrition.\nGU Pt with minimal UO 40cc with sbp 140's tonight. Pt continues to be positive. Wt up several kg. See flow for change. Urine is alkalinized as of ph 8.\nSocial. Family at bs till 10pm updated and educated via nursing staff of m/t/p. will continue to teach.\n\n" }, { "category": "Nursing/other", "chartdate": "2192-07-30 00:00:00.000", "description": "Report", "row_id": 1267503, "text": "NPN-MICU\nMr. to recover slowly.\nNeuro: he to be more sleepy in the am but more awake in the early afternoon. He was able to interact with his mom. His speech is still sl slurred with a weak voice but he is able to get his needs across.He to be able to lift and hold his rt side and can hold his left upper arm up but he can only minimally move his left leg. He follows simple commands. Psych eval done but he was hard to understand therefore will 1:1 sitters for now. No signs of sz or withdrawal symptoms so no sedatives needed. To get EMG to eval for lumbar plexus neuropathy\nGU: pt HD well, 2L removed, Quintan to be removed and resited if needed. No perma cath until pt afebrile. He to make min urine. Will increase calcium and add amphogel.\nGI: pt still thirsty,NGT fluid boluses increased. He to drink cl liqs without dificulty. He had lg liq stool, spec sent for C.Diff. pLan RUQ u/s to eval for galstones.No signs of aspirations, stool blueish\nCV: he remains in NSR, no VEA stable BP on clonipine. Echo done, prelim neg\nResp: on 2l NP will cough on command but not on own, lungs are clr with good o2 sats.\nID:WBC still up at 31 and spiked at 4pm, cx still pnd on IV AB. want to pull quintan cx line tip.\nSkin: no changes noted from the 3 pressure sore sites.Butt is very red, cream and talc applied.\nA/P: Will to eval mental status for changes and note left leg mvmt. Monitor for signs of withdrawal.\n House staff to remove Quintan and follow BUN/CR and u/o. Daily wts needed to follow lytes for replacement.\n follow TF rsp and stool amts, If pt more awake in the am ? feeding po vs TF.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-31 00:00:00.000", "description": "Report", "row_id": 1267504, "text": "NURSING PROGRESS NOTE 7P-7A\nREPORT RECEIVED AT 1900. PT'S ENVIRONMENT SECURED FOR SAFETY, ALL ALARMS ON MONOTR ARE FUNCTIONING.\n\nNEURO: PT. MORE INTACT AND ORIENTED X 3 TODAY. SPEECH IS MUCH CLEARER. PT. HAS BEEN CONVERSING AND APPROPRIATE IN EXPRESSING HIS NEEDS AND WANTS. PERLA. NO SEIZURE ACTIVITY NOTED. MAE X 4 WITH NOTICABLE WEAKER LOWER LEFT EXTREMETIY- HE IS ABLE TO MOVE THE LEFT LOWER EXTREMITY ON THE BED WITH MUCH EFFORT BUT IS NOT ABLE TO LIFT AND HOLD. NOTED IMPROVEMENT IN STRENGTH SINCE YESTERDAY. 1:1 SITTER CONTINUES FOR SUICIDE PRECAUTIONS. OBEYS COMMANDS WITHOUT DIFFICULTY. COOPERATIVE AND CALM.\n\nRR: PT REMAINS ON 2L NC WITH NO DIFFICULTY BREATHING OR COMPLAINTS OF SOB. BBS= ESSENTIALLY CLEAR. PT HAS IMPROVED COUGH EFFORT. WILL COUGH AND DEEP BREATHE WHEN ENCOURAGED. NO SECRETIONS EXPECTORATED. RR 15-20, SP02 98-100%. BILATERAL CHEST EXPANSION NOTED.\n\nCV: PT HAS BEEN NSR WITH NO SIGNS OF ECTOPY, HR 70-90'S. SBP > THAN 100 WITH NO SYMPTOMATIC HYPER OR HYPOTENSIVE CRISES. LEFT RADIAL ALINE IS SECURE AND INTACT, REZEROED AND RECALIBRATED DURING THE SHIFT. BILATERAL RADIAL AND DORSALIS PEDIS PULSES ARE EAISLY PALPABLE. CAP REFILL X 4 EXTREMETIES IS < 3. NO SIGNS OF JVD NOTED. S1 AND S2 AS PER AUSCULTATION. NO RUBS, GALLOPS OR MURMURS AUSCULTATED.\n\nGI: ABD IS SOFT, NON-TENDER TO PALPATION. BS X 4 QUADRANTS. NG TO LEFT NARE IS SECURE AND PATENT WITH POSITIVE PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC OF AIR. TUBE FEEDS ARE AT GOAL RATE OF 40CC/HR WITH 10CC RESIDUALS. PT HAS BEEN TOLERATING PO LIQUIDS AND ATE ONE CUP OF JELLO, NO COMPLAINTS OF N/V. PT HAS HAD TWO LARGE BROWN-BLUE TINTED STOOLS- LIQUID IN CONSISTENCY.\n\nGU: OLIGURIC- MINIMAL UOP AT 5-10CC/HR, AMBER, CLEAR URINE. DIALYSIS ON WEDNESDAY. RENAL MD AWARE OF PT'S PROGRESS.\n\nID: CONTACT PRECAUTIONS FOR MRSA.\n\nINTEG: NO CHANGES IN LESIONS TO BILATERAL ANKLES. BACK AND BUTTOCKS ARE STILL REDDENED- PROTECTIVE BARRIER OINTMENT AND TALC AS WELL AS FREQUENT REPOSITIONING TO PREVENT FURTHER BREAKDOWN.\n\nPLAN: POSSIBLE CALL OUT TODAY. WILL CONTINUE TO MONITOR AND TREAT ELECTROLYTES AS NEEDED. TREAT WITH ANTIBIOTICS AS NEEDED. CONTINUE 1:1 SITTER UNTIL FURTHER PSYCH EVALUATION. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n" }, { "category": "Nursing/other", "chartdate": "2192-07-31 00:00:00.000", "description": "Report", "row_id": 1267505, "text": "FOCUS: NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- PATIENT ORIENTED TO PLACE AND PERSON THIS AM NOT ORIENTED TO TIME. LATER IN DAY ORIENTED TO TIME. HE IS LETHARGIC. DOES OBEY COMMANDS. SLEEPING GOOD PART OF DAY. POS GAG.\nRESP- ON 2L NC SATS IN HIGH 90'S. RESP 16-18. ENCOURAGED TO COUGH AND DEEP BREATH.\nCARDIAC- HR 70-90'S NSR W/O ECTOPI. SBP BY ALINE 35 PTS HIGHER THAN CUFF. SBP BY CUFF 117-135. CONTINUES ON CLONIDINE.\nGI- ABD SOFT WITH POS BS. HAD DIARRHEA X1 TODAY BLUE GRREN LIQUID STOOL UNABLE TO GUIAC DUE TO THE COLOR. NEPRO CHANGED TO ADD 35GMS PROMOD TO FS NEPRO. RATE DECREASED TO 35CC/HR. NOT GIVEN PO'S TODAY AS TO BE EVALUATED BY SPEECH AND SWOLLOW TO MAKE SURE HE ISN'T ASPIRATING DUE TO HIGH WBC.\nGU- FOLEY PATENT DRAINING 4-35CC/HR. NO LONGER WITH HEMODIALYSIS ACCESS. ? IF WILL BE DIALYZED TOMMORROW. RENAL TO DECIDE. ? TEMP CATH OR PERMACATH TO BE PLACED DEPENDING ON FEVER CURVE AND WBC.\nID- WBC DOWN TO 25.5. CONTINUES ON FLAGYL, LEVO, AND VANCO. RANDOM VANCO LEVEL 6.4 TODAY. RECEIVED 1GM VANCO X 1 TODAY.\nDISPO- TO FLOOR WITH 1;1 SITTER WHEN BED AVAILABLE. PER PSYCHE 1;1 SITTER IS TO CONTINUE UNTIL HE IS MORE ALERT.\n MOM VISITED TODAY AND WAS UPDATED ON THE PATIENT'S CONDITION.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-22 00:00:00.000", "description": "Report", "row_id": 1267482, "text": "RESP CARE NOTE\nPT RECEIVED FROM EW, INTUBATED 2ND RHABDOMYOLYSIS/DRUG O.D. MANUALLY VENTILATED VIA 100% AMBU FROM EW. PLACED ON SERVO 900C VENT 700 X 14, 100%, 12. SEE FLOWSHEET FOR ABGS & MULTIPLE VENT CHANGES. CURRENT SETTINGS A/C 700 X 21, 80% 12P. BS COARSE RALES T.O., SXN FOR LG AMT FLORID PULM EDEMA. PT HEAVILY SEDATED & IN SYNCH W/VENT. ACID BASE REVEALS SEVERE COMBINED RESPIRATORY & METABOLIC ACIDOSIS W/SEVERE HYPOXIA. LT RADIAL ART LINE & SWAN GANZ LINE PLACED IN ICU. ULTRAFILTRATION HEMODIALYSIS STARTED. PLAN TO MONITOR CLOSELY, WEAN FI02 AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-22 00:00:00.000", "description": "Report", "row_id": 1267483, "text": "Neuro Pt following commands and sl nodding head at 0130. Pt sedated for ventilation purposes. Pt on Fentanyl 200mcg/hr and Ativan 12mg/hr. Pt now unresponsive GCS 3. PERRLA. Pt with CT scan of head at hosp insignificant.\nCard. Pt with HR 80-90's. BP very labile Dopa now at 10 mcg/kg/min. See flow for lines placed. Awaiting cxr for swan placement. Unable to obtain accurate mixed venous gas drawn X 2 ? swan placement. PCWP 12 PA's 28/12 CVP 8. Labs K 6.6 on arrival given kayexalate, iCa.84 given 4amps Cagluc. CK 100,000! Need to recheckthis am. Pt now being dyalized. 0500 labs not corrected awaiting end of dyalisis.\nRR Pt with multiple vent changes over night. Pt with pulmonary edema? Pink frothy sputum from ETT and poor O2 sats 70's. Pt with sx'g. L lung with asp pneum. See abg per flow.\nGI Pt with OGT guaic - ph . protonix coverage. Bs ok.\nGU Pt with minimal UO approx 7L pos today. Pt being dyalized at present time. Urine dark amber color sent for labs this am.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-22 00:00:00.000", "description": "Report", "row_id": 1267484, "text": "\nPt has made ever so slight progress.\nResp: we have been able to drop his Fio2 to 40%. He cont to have frothy sputum(sl less thru day) so we have left the PEEP at 12cm. Lungs still with crackles but his ABG and O2 sats have improved. Post HD his pH has increased to 7.41 and so we have been able to drop his RR to 14 with improved ventilations. His pleateau pressures and compliance have remained WNL.No improvement in CXR this am.\nCV:pt cont to be dopamine dependent, attempts at weaning have dropped BP to <70. We have been given IVF to get his CVP upto 13-15 and PCWP 15-18. His lytes have corrected s/p HD and 6pm repeats are pnd. His HR has dropped nicely as he has dropped his fever remains in SR. His CO has improved with increased vol and his SVR is still high at \nGU: tol HD well and will prob have another tomorrow. His BUN/CR are down 30/2.5 His u/o cont to be at 14-15cc/hr despite fluid replacement.Calcium not replaced , come up on own\nGI:he cont with OGT to sx, bilious, no stool min bowel sounds. He has elevated LFT's and remains NPO for now.\nHeme:sl + DIC ( +D-Dimer, NL FDP&fibrogen). Hct stable at 44, no obvious bleeding\nID: spiked 101 this am cx all pnd, IVAB renal dose, tyleonl with good results.\nNeuro:pt cont to be sedated on fentanyl and ativan sl decreased as pt is totally unrsp. PERL,winces wtih mouth care.\nSkin:pt with 3 sites of ? pressure sores, left butt,rt shin and lt ankle.All red but not breakthrough. Tryadyne bed obtained for ?ARDS and hypotension. He does not tol having his rt side down as yet.\nSocial: pt's parents have been in and out all day, updated by nursing.\nA/P:Pt tol decrease of FIo2 but still with ?ARDS picture\n Will cont to follow ABG and acidosis, with cont improvements ? dropping PEEP while cont to follow MV,compliance and plateau pressues for signs of increased ARDS, adjust vent as needed\n Closely follow PA pressure readings to get to target CVP and PCWP and watch o2 sats to avoid fluid overload/capillary leakage\n Wean Dopa to keep MAP >60, check CPK's in am\n Check lytes for 6pm, note u/o and I&O, HD in am\n Wean sedatives to keep pt comfort on vent but totally out of it.\n Watch for signs of DIC.\n NPO for now, note OGt asp.\n Cont IVAB, tylenol for fever\n" }, { "category": "Nursing/other", "chartdate": "2192-07-29 00:00:00.000", "description": "Report", "row_id": 1267499, "text": "NURSING PROGRESS NOTE 7P-7A\n(Continued)\n NO COMPLAINTS OF DISCOMFORT WHEN VOIDING.\n\nINTEG: NO CHANGES IN LESIONS TO BILATERAL LOWER EXTREMETIES OR TO BUTTOCKS. LEFT ARM IS STILL REDDENED WITH EDEMA BUT HAS NOT WORSENED. WILL CONTINUE TO MONITOR.\n\nPLAN: WILL CONTINUE TO MONITOR NEURO STATUS AND RESPIRATORY STATUS. 1:1 SITTER FOR SUICIDE PRECAUTIONS. WILL CONTINUE TO MONITOR ELECTROLYTES AND TREAT AS NEEDED. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\nSOCIAL: FAMILY AWARE OF PT'S CONDITION. NO ISSUES.\n" }, { "category": "Nursing/other", "chartdate": "2192-07-29 00:00:00.000", "description": "Report", "row_id": 1267500, "text": "Nursing note from Micu B 0700-1900\n\nNeuro: Significant change from yesterday. Pearl 3 mm brisk, slept all shift, at times pt was unarousable to sternal rub. Infrequently will open eyes. Does not move any extremities. miminal reflexes on the left leg. Increased edema noted on left side of trunk, leg and hand. Hand and leg up on pillows. + pitting edema. Percocet was dc'd.\n\nResp: on nasal o2 at 2 liters sat's 96-99% no sob, unable to get secretions when suctioned. Spcul needed when able. no resp distress.\n\nCV: Aline in place, good wave form, dressing dry and intact. sharp.\nabg's drawn this am 7.36/29/136 and again at 1300 7.36/31/127.\nTeam wants us to monitor at times his NIBP from the right arm, very little change, points. Central line wire changed over, tip sent for culture. Cxr done to confirm placement, good placement.\nNSR 70-80's no ectopy noted.\n\nGI/GU: hasn't move his bowels today. very little urin from foley, dark yellow to amber urine. ucul and ua sent.\npositive bowel sounds, hypoactive, tf at 35 cc per hr, goal is at 40 cc per hr. no residuals noted. placement checked several times througout the shift.\n\nSkin: lesions haven't changed. edema noted on scrotal area, more edema on left ahnd, thing and abd.\n\nInfection: pt spiked temp 3 pm 101.4 tylenol given given, 6 pm temp 101.2. Bculs x 2 sent, today, ua/ucul sent and tip sent for culture.\nremains on same antibiotics, vanco level was drawn. at 1800\n\nTest: Pt had ultrasound on left leg, results pending, eeg done, results pending, tap left for pleural effusion 700cc of serous fluid.\n\nSocial: family very supportive at bedside. 1:1 when family isn't at bedside.\n" } ]

[ { "category": "Radiology", "chartdate": "2184-06-13 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 1076495, "text": " 1:22 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for infectious process\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n eval for infectious process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc SUN 5:09 PM\n No acute abnormalities. Stable dilated GB without evidence of cholecystitis.\n Stable dilated CBD to 12mm without obstructing lesion or stone seen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with abdominal pain.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis. No contrast was administered due to elevated creatinine. Oral\n contrast was administered. Multiplanar reformatted images were generated.\n\n CT ABDOMEN WITHOUT IV CONTRAST: At the lung bases, there is mild dependent\n atelectasis, but no consolidation or pleural effusion. There is no\n pericardial effusion. Calcification of coronary arteries is again noted.\n\n In the abdomen, evaluation of solid organs is limited in the absence of IV\n contrast. However, the gallbladder remains distended, without wall\n thickening, wall edema, or pericholecystic fluid to suggest acute\n cholecystitis. A small gallstone again layers dependently at the gallbladder\n fundus. The liver, pancreas, spleen, stomach, duodenum, adrenal glands, and\n kidneys are grossly unremarkable. No radiopaque calculi or other obstructing\n lesion is identified. Extensive atherosclerotic calcification of the\n abdominal aorta and its branches is stable. There is no free air or free\n fluid in the abdomen.\n\n CT PELVIS WITHOUT IV CONTRAST: Multiple loops of large and small bowel are\n unremarkable. There is no evidence of obstruction. There are no inflammatory\n changes surrounding the bowel. Evaluation of the lower pelvis is limited\n given streak artifact from bilateral hip prostheses. However, the uterus and\n adnexa are unremarkable. The urinary bladder is collapsed around a Foley\n catheter. There is no free fluid in the pelvis.\n\n There is no abdominal or pelvic lymphadenopathy by size criteria.\n\n OSSEOUS STRUCTURES: There is no fracture or worrisome lytic or sclerotic bony\n lesion. There is mild anterolisthesis and degenerative change at L5-S1.\n Within the subcutaneous tissues of the anterior abdominal wall, there are\n bilateral soft tissue density lesions, likely related to injections.\n\n IMPRESSION:\n (Over)\n\n 1:22 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for infectious process\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No abnormalities in the abdomen or pelvis to explain pain.\n 2. Stably distended gallbladder without evidence of acute cholecystitis.\n 3. No change in enlarged common bile duct without visualized stone or other\n obstructive lesion.\n 4. Extensive atherosclerotic calcification.\n\n" }, { "category": "Physician ", "chartdate": "2184-06-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 571418, "text": "Chief Complaint: weakness, admitted to ICU for metabolic acidosis\n HPI:\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Respiratory: Cough\n Gastrointestinal: Abdominal pain, Nausea, Diarrhea\n Flowsheet Data as of 09:34 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (78 - 83) bpm\n BP: 142/70(92) {132/70(89) - 142/78(92)} mmHg\n RR: 22 (18 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -190 mL\n Respiratory\n SpO2: 99%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-06-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 571420, "text": "Chief Complaint: weakness, admitted to ICU for metabolic acidosis\n HPI: This is a 62 year old female with Hep C, CRI who presents with\n weakness admitted to the ICU for metabolic acidosis. She states that\n since yesterday, she has felt \"soreness all over\" particularly in\n shoulders, back and chest as well as abdominal pain. She also reports\n some nausea but denies vomiting. She states that she has had copius\n diarrhea, >30BM's daily, which has been present for months since she\n C.diff diagnosis. She reports mild intermittent non-productive cough.\n She endorses chills, but no overt fever\n .\n Of note, the patient has had multiple admissions this year. She was\n admitted to the ICU in for Ecoli bacteremia,\n pyelonephritis and sepsis complicated by HAP and C.diff. She was\n readdmited for abdominal pain and diarrhea kayaxalate. She was\n admitted again to the surgery service on for SBO,\n received conservative therapy - NP, NG suction and slowly advancing\n diet.\n .\n In the ED: The patient was noted to havea leukocytosis, elevated Cr,\n metabolic acidosis with ph 7.18/38/65 A CXR was neg. CT abd showed a\n dilated gall bladder w/o stones which is unchanged from prior. She\n received Vanc,levaquin and flagyl for ? CAP and C.diff. She also was\n started on fluids.\n - vitals 97.0 64 132/74 16 100\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\n times a day).\n Folate 1'\n Lopressor 25''\n Trazodone 150HSprn\n Calcitriol 0.25'\n Past medical history:\n Family history:\n Social History:\n CKD Stage III\n Hepatitis C\n Emphysema\n Mild MR\n Mod TR\n Mod Pulm HTN\n LLL nodule\n GERD\n Hiatal hernia\n Polysubstance abuse\n Left hip fracture s/p ORIF \n Right hip osteoarthritis s/p THR\n Psoriasis\n n/c\n Alcohol pint vodka/da, denies recent use.. Tobacco 1 ppd x 30\n years. Cocaine use. Hx IVDU within last year. Lives with fiance and\n mother.\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Respiratory: Cough\n Gastrointestinal: Abdominal pain, Nausea, Diarrhea\n Flowsheet Data as of 09:34 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (78 - 83) bpm\n BP: 142/70(92) {132/70(89) - 142/78(92)} mmHg\n RR: 22 (18 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -190 mL\n Respiratory\n SpO2: 99%\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no agiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology\n CT abd: No acute abnormalities. Stable dilated GB without evidence of\n cholecystitis. Stable dilated CBD to 12mm without obstructing lesion or\n stone seen.\n CXR: FRONTAL VIEW, CHEST: New right IJ CV catheter noted with tip in\n the expected location of the cavoatrial junction. The lungs are clear\n without evidence of pneumonia, CHF. There is improved aeration at the\n left base compared with prior. There is no pleural effusion or\n pneumothorax. Heart size is normal.\n Aortic knob calcifications are noted.\n IMPRESSION: No acute cardiopulmonary process. Right IJ CV catheter tip\n in the cavoatrial junction.\n .\n Micro:\n : C.diff +\n : C.diff neg\n + : VRE\n .\n EKG:\n NSR, no peaked T\ns, TWI in VI- V3, Normalization of TW in V4-V6\n comparied to prior, t waves in II, II, AVF now upright comparied to\n flat twaves one weak ago\n 207\n 126\n 3.2\n 26\n 11\n 107\n 5.3\n 127\n 36\n 14.7\n [image002.jpg] AG 13\n Lactate 2.6\n Trop <0.01\n CK 13\n AST 73\n ALT 90\n Alk Phos 188\n T. Bili 0.3\n Alb 3.5\n Assessment and Plan\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Non-gap metabolic acidosis with inadequate\n respiratory compensation, nl cl. Bicarbonate appears to be chronically\n low at around 15; however, given severely low pH there may be an acute\n component. On admission one week ago, presented with bicarbonate of 13\n and was discharged at 19. She has also received PO bicarbonate\n supplementation in the past. Etiology is likely diarrhea and renal\n failure. However, mineralocorticoid can also present as low bicarbonate\n and high K.\n - obtain urine gap and Ph\n - obtain TTKG\n - IVF with bicarb\n - alternate lactated ringers and NS for hydration\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear \n - stool studies and c.diff\n .\n # Weakness/ Soreness: Currently, she appears stable w/o fever and with\n nl BP, mentating well although she does have a leukocytosis. Unclear\n etiology at this time although electrolyte abnl vs chronic diarrhea vs\n viral illness vs flu are possible. Her current presentation seems to be\n c/w prior admissions for abd pain and FTT; however, she has also had\n serious illness in the past. IVDU raises ? on infection, HIV,\n endocardidits? She was recently HIV neg and currently denies IVDU.\n Hepatitis C may also make her feel weak if viral loads are rising. CXR\n w/o PNA. As there is no definate infection and as pt is stable, will\n hold off on abx.\n - hold abx and await cultures\n - r/o flu\n - f/u blood cx and stool studies\n - obtain UA and urine cx\n - check hepatitis viral load\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation.\n - obtain urine lytes\n - IVF\n .\n # R/o Flu:\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n .\n #Hx LLL nodule - Repeat chest CT recommended for .\n .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n .\n #) Prophylaxis: PPI, sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: no indication\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2184-06-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 571421, "text": "Chief Complaint: weakness, admitted to ICU for metabolic acidosis\n HPI: This is a 62 year old female with Hep C, CRI who presents with\n weakness admitted to the ICU for metabolic acidosis. She states that\n since yesterday, she has felt \"soreness all over\" particularly in\n shoulders, back and chest as well as abdominal pain. She also reports\n some nausea but denies vomiting. She states that she has had copius\n diarrhea, >30BM's daily, which has been present for months since she\n C.diff diagnosis. She reports mild intermittent non-productive cough.\n She endorses chills, but no overt fever\n .\n Of note, the patient has had multiple admissions this year. She was\n admitted to the ICU in for Ecoli bacteremia,\n pyelonephritis and sepsis complicated by HAP and C.diff. She was\n readdmited for abdominal pain and diarrhea kayaxalate. She was\n admitted again to the surgery service on for SBO,\n received conservative therapy - NP, NG suction and slowly advancing\n diet.\n .\n In the ED: The patient was noted to havea leukocytosis, elevated Cr,\n metabolic acidosis with ph 7.18/38/65 A CXR was neg. CT abd showed a\n dilated gall bladder w/o stones which is unchanged from prior. She\n received Vanc,levaquin and flagyl for ? CAP and C.diff. She also was\n started on fluids.\n - vitals 97.0 64 132/74 16 100\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\n times a day).\n Folate 1'\n Lopressor 25''\n Trazodone 150HSprn\n Calcitriol 0.25'\n Past medical history:\n Family history:\n Social History:\n CKD Stage III\n Hepatitis C\n Emphysema\n Mild MR\n Mod TR\n Mod Pulm HTN\n LLL nodule\n GERD\n Hiatal hernia\n Polysubstance abuse\n Left hip fracture s/p ORIF \n Right hip osteoarthritis s/p THR\n Psoriasis\n n/c\n Alcohol pint vodka/da, denies recent use.. Tobacco 1 ppd x 30\n years. Cocaine use. Hx IVDU within last year. Lives with fiance and\n mother.\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Respiratory: Cough\n Gastrointestinal: Abdominal pain, Nausea, Diarrhea\n Flowsheet Data as of 09:34 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (78 - 83) bpm\n BP: 142/70(92) {132/70(89) - 142/78(92)} mmHg\n RR: 22 (18 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -190 mL\n Respiratory\n SpO2: 99%\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no agiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology\n CT abd: No acute abnormalities. Stable dilated GB without evidence of\n cholecystitis. Stable dilated CBD to 12mm without obstructing lesion or\n stone seen.\n CXR: FRONTAL VIEW, CHEST: New right IJ CV catheter noted with tip in\n the expected location of the cavoatrial junction. The lungs are clear\n without evidence of pneumonia, CHF. There is improved aeration at the\n left base compared with prior. There is no pleural effusion or\n pneumothorax. Heart size is normal.\n Aortic knob calcifications are noted.\n IMPRESSION: No acute cardiopulmonary process. Right IJ CV catheter tip\n in the cavoatrial junction.\n .\n Micro:\n : C.diff +\n : C.diff neg\n + : VRE\n .\n EKG:\n NSR, no peaked T\ns, TWI in VI- V3, Normalization of TW in V4-V6\n comparied to prior, t waves in II, II, AVF now upright comparied to\n flat twaves one weak ago\n 207\n 126\n 3.2\n 26\n 11\n 107\n 5.3\n 127\n 36\n 14.7\n [image002.jpg] AG 13\n Lactate 2.6\n Trop <0.01\n CK 13\n AST 73\n ALT 90\n Alk Phos 188\n T. Bili 0.3\n Alb 3.5\n Assessment and Plan\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Non-gap metabolic acidosis with inadequate\n respiratory compensation, nl cl. Bicarbonate appears to be chronically\n low at around 15; however, given severely low pH there may be an acute\n component. On admission one week ago, presented with bicarbonate of 13\n and was discharged at 19. She has also received PO bicarbonate\n supplementation in the past. Etiology is likely diarrhea and renal\n failure. However, mineralocorticoid can also present as low bicarbonate\n and high K.\n - obtain urine gap and Ph\n - obtain TTKG\n - IVF with bicarb\n - alternate lactated ringers and NS for hydration\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear \n - stool studies and c.diff\n .\n # Weakness/ Soreness: Currently, she appears stable w/o fever and with\n nl BP, mentating well although she does have a leukocytosis. Unclear\n etiology at this time although electrolyte abnl vs chronic diarrhea vs\n viral illness vs flu are possible. Her current presentation seems to be\n c/w prior admissions for abd pain and FTT; however, she has also had\n serious illness in the past. IVDU raises ? on infection, HIV,\n endocardidits? She was recently HIV neg and currently denies IVDU.\n Hepatitis C may also make her feel weak if viral loads are rising. CXR\n w/o PNA. As there is no definate infection and as pt is stable, will\n hold off on abx.\n - hold abx and await cultures\n - r/o flu\n - f/u blood cx and stool studies\n - obtain UA and urine cx\n - check hepatitis viral load\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation.\n - obtain urine lytes\n - IVF\n .\n # R/o Flu:\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n .\n #Hx LLL nodule - Repeat chest CT recommended for .\n .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n .\n #) Prophylaxis: PPI, sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: no indication\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ------ Protected Section ------\n Problem list cont:\n # Hyperkalemia: Likely renal failure, no peaked Twaves\n - monitor closely\n - obtain urine TTKG\n ------ Protected Section Addendum Entered By: , MD\n on: 22:29 ------\n" }, { "category": "Physician ", "chartdate": "2184-06-13 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 571422, "text": "Chief Complaint: weakness, admitted to ICU for metabolic acidosis\n HPI: This is a 62 year old female with Hep C, CRI who presents with\n weakness admitted to the ICU for metabolic acidosis. She states that\n since yesterday, she has felt \"soreness all over\" particularly in\n shoulders, back and chest as well as abdominal pain. She also reports\n some nausea but denies vomiting. She states that she has had copius\n diarrhea, >30BM's daily, which has been present for months since she\n C.diff diagnosis. She reports mild intermittent non-productive cough.\n She endorses chills, but no overt fever\n .\n Of note, the patient has had multiple admissions this year. She was\n admitted to the ICU in for Ecoli bacteremia,\n pyelonephritis and sepsis complicated by HAP and C.diff. She was\n readdmited for abdominal pain and diarrhea kayaxalate. She was\n admitted again to the surgery service on for SBO,\n received conservative therapy - NP, NG suction and slowly advancing\n diet.\n .\n In the ED: The patient was noted to havea leukocytosis, elevated Cr,\n metabolic acidosis with ph 7.18/38/65 A CXR was neg. CT abd showed a\n dilated gall bladder w/o stones which is unchanged from prior. She\n received Vanc,levaquin and flagyl for ? CAP and C.diff. She also was\n started on fluids.\n - vitals 97.0 64 132/74 16 100\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2\n times a day).\n Folate 1'\n Lopressor 25''\n Trazodone 150HSprn\n Calcitriol 0.25'\n Past medical history:\n Family history:\n Social History:\n CKD Stage III\n Hepatitis C\n Emphysema\n Mild MR\n Mod TR\n Mod Pulm HTN\n LLL nodule\n GERD\n Hiatal hernia\n Polysubstance abuse\n Left hip fracture s/p ORIF \n Right hip osteoarthritis s/p THR\n Psoriasis\n n/c\n Alcohol pint vodka/da, denies recent use.. Tobacco 1 ppd x 30\n years. Cocaine use. Hx IVDU within last year. Lives with fiance and\n mother.\n Review of systems:\n Constitutional: Fatigue, Weight loss\n Ear, Nose, Throat: Dry mouth\n Respiratory: Cough\n Gastrointestinal: Abdominal pain, Nausea, Diarrhea\n Flowsheet Data as of 09:34 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (78 - 83) bpm\n BP: 142/70(92) {132/70(89) - 142/78(92)} mmHg\n RR: 22 (18 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10 mL\n PO:\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -190 mL\n Respiratory\n SpO2: 99%\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no agiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology\n CT abd: No acute abnormalities. Stable dilated GB without evidence of\n cholecystitis. Stable dilated CBD to 12mm without obstructing lesion or\n stone seen.\n CXR: FRONTAL VIEW, CHEST: New right IJ CV catheter noted with tip in\n the expected location of the cavoatrial junction. The lungs are clear\n without evidence of pneumonia, CHF. There is improved aeration at the\n left base compared with prior. There is no pleural effusion or\n pneumothorax. Heart size is normal.\n Aortic knob calcifications are noted.\n IMPRESSION: No acute cardiopulmonary process. Right IJ CV catheter tip\n in the cavoatrial junction.\n .\n Micro:\n : C.diff +\n : C.diff neg\n + : VRE\n .\n EKG:\n NSR, no peaked T\ns, TWI in VI- V3, Normalization of TW in V4-V6\n comparied to prior, t waves in II, II, AVF now upright comparied to\n flat twaves one weak ago\n 207\n 126\n 3.2\n 26\n 11\n 107\n 5.3\n 127\n 36\n 14.7\n [image002.jpg] AG 13\n Lactate 2.6\n Trop <0.01\n CK 13\n AST 73\n ALT 90\n Alk Phos 188\n T. Bili 0.3\n Alb 3.5\n Assessment and Plan\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Non-gap metabolic acidosis with inadequate\n respiratory compensation, nl cl. Bicarbonate appears to be chronically\n low at around 15; however, given severely low pH there may be an acute\n component. On admission one week ago, presented with bicarbonate of 13\n and was discharged at 19. She has also received PO bicarbonate\n supplementation in the past. Etiology is likely diarrhea and renal\n failure. However, mineralocorticoid can also present as low bicarbonate\n and high K.\n - obtain urine gap and Ph\n - obtain TTKG\n - IVF with bicarb\n - alternate lactated ringers and NS for hydration\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear \n - stool studies and c.diff\n .\n # Weakness/ Soreness: Currently, she appears stable w/o fever and with\n nl BP, mentating well although she does have a leukocytosis. Unclear\n etiology at this time although electrolyte abnl vs chronic diarrhea vs\n viral illness vs flu are possible. Her current presentation seems to be\n c/w prior admissions for abd pain and FTT; however, she has also had\n serious illness in the past. IVDU raises ? on infection, HIV,\n endocardidits? She was recently HIV neg and currently denies IVDU.\n Hepatitis C may also make her feel weak if viral loads are rising. CXR\n w/o PNA. As there is no definate infection and as pt is stable, will\n hold off on abx.\n - hold abx and await cultures\n - r/o flu\n - f/u blood cx and stool studies\n - obtain UA and urine cx\n - check hepatitis viral load\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation.\n - obtain urine lytes\n - IVF\n .\n # R/o Flu:\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n .\n #Hx LLL nodule - Repeat chest CT recommended for .\n .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n .\n #) Prophylaxis: PPI, sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: no indication\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ------ Protected Section ------\n Problem list cont:\n # Hyperkalemia: Likely renal failure, no peaked Twaves\n - monitor closely\n - obtain urine TTKG\n ------ Protected Section Addendum Entered By: , MD\n on: 22:29 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient with Dr. . I have reviewed the\n details of the H&P and have confirmed her findings. I would emphasize\n and add the following points:\n Although Ms is hemodynamically stable, she is admitted to the\n MICU due to the severe metabolic acidosis and likely respiratory\n acidosis. She has profuse diarrhea by history. On review of her recent\n radiology exams, she underwent a CT scan of her chest in ,\n which revealed severe emphysema in addition to her pneumonia. She is\n not likely able to compensate for her metabolic acidosis due to her\n emphysema. Unfortunately, we cannot find a previous blood gas nor\n PFTs.\n I agree with Dr. \ns assessment and plan. We will ask Renal to\n see her in the morning. She will need workup for her diarrhea, and we\n should send a blood gas when she is not acutely ill.\n Total time: 70 min\n ------ Protected Section Addendum Entered By: , MD\n on: 22:44 ------\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 571500, "text": "Chief Complaint: weakness\n 24 Hour Events:\n MULTI LUMEN - START 08:00 PM\n - received IVF fluids with bicarbonate, then started on NS\n - repeat ABG improved pH now 7.3\n - K down to 3.8\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 82 (71 - 90) bpm\n BP: 97/47(59) {91/46(59) - 142/78(92)} mmHg\n RR: 14 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,117 mL\n PO:\n TF:\n IVF:\n 480 mL\n 1,117 mL\n Blood products:\n Total out:\n 270 mL\n 130 mL\n Urine:\n 270 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 210 mL\n 987 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.30/28/49/19/-10\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 142 K/uL\n 9.4 g/dL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Ca++:7.5 mg/dL,\n Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n DIARRHEA\n .H/O ABDOMINAL COMPARTMENT SYNDROME / INTRAABDOMINAL HYPERTENSION\n (IAH, ACS)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ACIDOSIS, METABOLIC\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Improving after IVF with bicarbonate. Non-gap\n metabolic acidosis with inadequate respiratory compensation, nl cl.\n Bicarbonate appears to be chronically low at around 15; however, given\n severely low pH there may be an acute component. On admission one week\n ago, presented with bicarbonate of 13 and was discharged at 19. She has\n also received PO bicarbonate supplementation in the past. Etiology is\n likely diarrhea and renal failure. However, mineralocorticoid can also\n present as low bicarbonate and high K.\n - obtain urine gap and Ph\n - obtain TTKG\n - IVF with bicarb\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear \n - stool studies and c.diff\n .\n # Weakness/ Soreness: Unclear etiology at this time although chronic\n diarrhea is a possible etiology vs viral illness vs flu. her current\n presentation seems to be c/w prior admissions for abd pain and FTT;\n however, she has also had serious illness in the past. Currently, she\n appears stable w/o fever and with nl BP, mentating well.\n - r/o flu\n - f/u blood cx\n - obtain UA and urine cx\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation.\n - obtain urine lytes\n - IVF\n .\n # R/o Flu:\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No\n clinical stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n .\n #Hx LLL nodule - Repeat chest CT recommended for .\n .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n .\n #) Prophylaxis: PPI, sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 571501, "text": "Chief Complaint: weakness\n 24 Hour Events:\n MULTI LUMEN - START 08:00 PM\n - received IVF fluids with bicarbonate, then started on NS\n - repeat ABG improved pH now 7.3\n - K down to 3.8\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 82 (71 - 90) bpm\n BP: 97/47(59) {91/46(59) - 142/78(92)} mmHg\n RR: 14 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,117 mL\n PO:\n TF:\n IVF:\n 480 mL\n 1,117 mL\n Blood products:\n Total out:\n 270 mL\n 130 mL\n Urine:\n 270 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 210 mL\n 987 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.30/28/49/19/-10\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no angiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology\n 142 K/uL\n 9.4 g/dL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Ca++:7.5 mg/dL,\n Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n DIARRHEA\n .H/O ABDOMINAL COMPARTMENT SYNDROME / INTRAABDOMINAL HYPERTENSION\n (IAH, ACS)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ACIDOSIS, METABOLIC\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Improving after IVF with bicarbonate. Non-gap\n metabolic acidosis with inadequate respiratory compensation, nl cl.\n Bicarbonate appears to be chronically low at around 15; however, given\n severely low pH there may be an acute component. On admission one week\n ago, presented with bicarbonate of 13 and was discharged at 19. She has\n also received PO bicarbonate supplementation in the past. Etiology is\n likely diarrhea and renal failure. However, mineralocorticoid can also\n present as low bicarbonate and high K.\n - obtain urine gap and Ph\n - obtain TTKG\n - IVF with bicarb\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear . This diarrhea appears to be chronic and\n profuse, possibly contributing to severe recurrent acid base\n disturbaces\n - stool studies and c.diff\n - may need coloncsopy and GI consult\n .\n # Weakness/ Soreness: Unclear etiology at this time although chronic\n diarrhea is a possible etiology vs viral illness vs flu. her current\n presentation seems to be c/w prior admissions for abd pain and FTT;\n however, she has also had serious illness in the past. Currently, she\n appears stable w/o fever and with nl BP, mentating well.\n - r/o flu\n - f/u blood cx\n - obtain UA and urine cx\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation.\n - obtain urine lytes\n - IVF\n .\n # R/o Flu:\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No\n clinical stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n .\n #Hx LLL nodule - Repeat chest CT recommended for .\n .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n .\n #) Prophylaxis: PPI, sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 571508, "text": "Chief Complaint: weakness\n 24 Hour Events:\n MULTI LUMEN - START 08:00 PM\n - received IVF fluids with bicarbonate, then started on NS\n - repeat ABG improved pH now 7.3\n - K down to 3.8\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 82 (71 - 90) bpm\n BP: 97/47(59) {91/46(59) - 142/78(92)} mmHg\n RR: 14 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,117 mL\n PO:\n TF:\n IVF:\n 480 mL\n 1,117 mL\n Blood products:\n Total out:\n 270 mL\n 130 mL\n Urine:\n 270 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 210 mL\n 987 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.30/28/49/19/-10\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no angiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology\n Urine anion gap: 49\n Urine pH: 5.5\n TTKG: 4.8\n 142 K/uL\n 9.4 g/dL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Ca++:7.5 mg/dL,\n Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n DIARRHEA\n .H/O ABDOMINAL COMPARTMENT SYNDROME / INTRAABDOMINAL HYPERTENSION\n (IAH, ACS)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ACIDOSIS, METABOLIC\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Improving after IVF with bicarbonate. Non-gap\n metabolic acidosis with inadequate respiratory compensation, nl cl.\n Bicarbonate appears to be chronically low at around 15; however, given\n severely low pH there may be an acute component. On admission one week\n ago, presented with bicarbonate of 13 and was discharged at 19. She has\n also received PO bicarbonate supplementation in the past. Etiology is\n likely diarrhea and renal failure. However, mineralocorticoid can also\n present as low bicarbonate and high K.\n - obtain urine gap and Ph\n - obtain TTKG\n - IVF with bicarb\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear . This diarrhea appears to be chronic and\n profuse, possibly contributing to severe recurrent acid base\n disturbaces\n - stool studies and c.diff\n - may need coloncsopy and GI consult\n .\n # Weakness/ Soreness: Unclear etiology at this time although chronic\n diarrhea is a possible etiology vs viral illness vs flu. her current\n presentation seems to be c/w prior admissions for abd pain and FTT;\n however, she has also had serious illness in the past. Currently, she\n appears stable w/o fever and with nl BP, mentating well.\n - r/o flu\n - f/u blood cx\n - obtain UA and urine cx\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation.\n - obtain urine lytes\n - IVF\n .\n # R/o Flu:\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No\n clinical stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n .\n #Hx LLL nodule - Repeat chest CT recommended for .\n .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n .\n #) Prophylaxis: PPI, sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 571606, "text": "Patient was seen, examined and case discussed with the ICU resident. I\n agree with their assessment and plan. Please see my note detailing the\n plan bellow.\n Chief Complaint: presents with weakness and metabolic acidosis.\n HPI: 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n She reports copious diarrhea no abdominal pain.\n She is also reporting bilateral shoulder pain right greater than left\n that is associated with movement and deep breaths. This has been worse\n over the last week.\n 24 Hour Events:\n Fluids 1L with bicarb and normal saline started.\n MULTI LUMEN - START 08:00 PM\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n cacitriol\n folic acid\n trazedone\n hep Sq tid\n zophran\n tramadol\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:Diarrhea and shoulder pain\n Flowsheet Data as of 09:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.2\n HR: 80 (71 - 90) bpm\n BP: 98/51(62) {91/46(59) - 142/78(92)} mmHg\n RR: 13 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,565 mL\n PO:\n 200 mL\n TF:\n IVF:\n 480 mL\n 1,365 mL\n Blood products:\n Total out:\n 270 mL\n 165 mL\n Urine:\n 270 mL\n 165 mL\n NG:\n Stool:\n 400cc since am\n Drains:\n Balance:\n 210 mL\n 1,400 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.36/30/81./19/-6\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD\n HEENT; moist MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: CTA bilaterally\n ABD: soft, NT, ND, +BS\n EXT: wasted, no gross motor or sensory deficits\n Labs / Radiology: CT abdomen unremarkable, chest x-ray negative per\n report\n 9.4 g/dL\n 142 K/uL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n 07:44 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n 18\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Lactic Acid:0.7\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Lipase-normal in past.\n Ua-small leuk few bacteria 7WBC PH 5.5\n Cr. 80, Na 68, K 27, Urine osm 310 Urine gap-49 TTKG-4.8\n C.Diff neg .\n Hx VRE\n HIV neg \n Assessment and Plan\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n # Metabolic acidosis: Non-gap metabolic acidosis\n - IVF with bicarb, will volume replete with NS then start oral bicitra.\n - will check orthostatics if orthostatic will give more NS\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear , secretory, secondary to etoh, infectious,\n or osmotic.\n - stool studies and c.diff\n - Send stool osms and fecal fat\n -Consider pancreatic insufficiency\n -If preliminary workup is negative will consult GI\n -D\nc antibiotics\n #Fatigue/shoulder and back pain-getting ruled out for flu very low\n suspicion presented with cough, myalgia started in the ED once DFA\n negative will stop given low suspicion.\n -Unclear etiology of myalgia\n -Normal CK\n -Will observe\n #Acute on chronic renal insufficiency - improved\n -Will need renal follow up.\n - obtain urine lytes\n - IVF\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n #Hx LLL nodule - Repeat chest CT recommended for .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition :Floor.\n Total time spent:\n ------ Protected Section ------\n Attending Note:\n I was physically present with the resident team and independently\n examined the patient on this date. I agree with the findings as\n described above including history, exam, ROS, Fam Hx and assessment and\n plan. 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure. Exam as above. Stable to transfer\n to the floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:46 ------\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 571466, "text": "This is a 62 year old female with Hep C, CRI who presents with weakness\n admitted to the ICU for metabolic acidosis. She states that since\n yesterday, she has felt \"soreness all over\" particularly in shoulders,\n back and chest as well as abdominal pain. She also reports some nausea\n but denies vomiting. She states that she has had copius diarrhea,\n >30BM's daily, which has been present for months since she C.diff\n diagnosis. She reports mild intermittent non-productive cough. She\n endorses chills, but no overt fever she is being R/O for the flu. Pt\n was sent to the MICU to try and correct her metabolic acidosis.\n .\n Diarrhea\n Assessment:\n Pt has hyperactive BS throughout. Pt has been c/o weakness and\n incontinence so a mushroom cath was placed. Pt is noted to have yellow\n colored loose diarrhea. Pt had a CT while in the ED which was normal/no\n changes from previous CT. P t has a history of c-diff. Pt denies ABD\n tenderness but will c/o nausea at times.\n Action:\n Pt had three stool samples sent to the lab. Pt had levaquin, vanco and\n flagyl given in the ED however, abx were not started here in the ICU.\n Response:\n Pt is resting in bed. Awaiting stool sample results.\n Plan:\n No treatment for the diarrhea at this time but continue to monitor\n output\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt C/O 10 out of 10 pain/soreness all over her body.\n Action:\n Pt had about 12mg of morphine in the ED with little to no relief. Here\n pt was started on Ultram 50mg \n Response:\n Pt stated she is more comfortable and resting in bed.\n Plan:\n Cont to monitor pain.\n .H/O acidosis, Metabolic\n Assessment:\n Upon arrival to MICU pt Ph was 7.18 in the ED. Pt appeared visibly\n dry. Pt electrolytes were all off----please see metavision.\n Action:\n Pt was started on a Bicarb gtt. Nephrology will be following the Pt for\n acute/chronic renal failure.\n Response:\n Pt last abg although possibly venous was within normal limits. Pt was\n also noted to have a high potassium while in the ED. Since pt is dry\n she will need multiple bags of fluid. We are gently rehydrating her\n with alternating bags NS and LR. Her urine output remains low, the MD\n are aware and believe this may be due to a progressively worsening\n kidney function.\n Plan:\n Renal involved, 1^st bag of NS is up at 120cc/hr. Once the NS finishes\n pt will need a bag of LR at 120cc/hr. Please re evaluate with MD prior\n to giving more fluid.\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 571462, "text": "This is a 62 year old female with Hep C, CRI who presents with weakness\n admitted to the ICU for metabolic acidosis. She states that since\n yesterday, she has felt \"soreness all over\" particularly in shoulders,\n back and chest as well as abdominal pain. She also reports some nausea\n but denies vomiting. She states that she has had copius diarrhea,\n >30BM's daily, which has been present for months since she C.diff\n diagnosis. She reports mild intermittent non-productive cough. She\n endorses chills, but no overt fever\n Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 571460, "text": "Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 571557, "text": "This is a 62 year old female with Hep C, CRI who presents with weakness\n admitted to the ICU for metabolic acidosis. She states that since\n yesterday, she has felt \"soreness all over\" particularly in shoulders,\n back and chest as well as abdominal pain. She also reports some nausea\n but denies vomiting. She states that she has had copius diarrhea,\n >30BM's daily, which has been present for months since she C.diff\n diagnosis. She reports mild intermittent non-productive cough. She\n endorses chills, but no overt fever she is being R/O for the flu. Pt\n was sent to the MICU to try and correct her metabolic acidosis.\n ICU COURSE:pt received bicarb in the MICU,rpt abd shows PH 7.36,contd\n have low urine output 15-20cc/hr,HCT dropped to 23(guaiac neg\n stool)..contd have loose bm .\n .\n Diarrhea\n Assessment:\n Abd soft +ve bowel sounds,denied abd pain but has gen body\n pain\nmushroom cath draining yellow loose stool, As per the pt she had\n ongoing issue of diarrhea for the last few months.\n Action:\n Stool has been sent for cx and infectious work up.contd na\n @120cc/hr,orthostatic VS were obtained.\n Response:\n Stool neg for c diff and ova and parasites,final work up pending.\n Plan:\n Plan for GI consult and possible colonoscopy after the preliminary work\n up,will cont the mushroom cath for now.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt C/O 10 out of 10 pain/soreness all over her body.\n Action:\n Pt had about 12mg of morphine in the ED with little to no relief. Here\n pt was started on Ultram 50mg \n Response:\n Pt stated she is more comfortable and resting in bed.\n Plan:\n Cont to monitor pain.\n .H/O acidosis, Metabolic\n Assessment:\n Upon arrival to MICU pt Ph was 7.18 in the ED. Pt appears visibly\n dry. With marked electrolyte imbalance.,received biacarb GTT\n overnight\n Action:\n Contd NS @120cc/hr. received 2gm of mgso4\n Response:\n UOP still 15-20cc/hr,ph improved to 7.36,\n Plan:\n Renal involved, follow fluid balance and labs.\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 571558, "text": "This is a 62 year old female with Hep C, CRI who presents with weakness\n admitted to the ICU for metabolic acidosis. She states that since\n yesterday, she has felt \"soreness all over\" particularly in shoulders,\n back and chest as well as abdominal pain. She also reports some nausea\n but denies vomiting. She states that she has had copius diarrhea,\n >30BM's daily, which has been present for months since she C.diff\n diagnosis. She reports mild intermittent non-productive cough. She\n endorses chills, but no overt fever she is being R/O for the flu. Pt\n was sent to the MICU to try and correct her metabolic acidosis.\n ICU COURSE:pt received bicarb in the MICU,rpt abd shows PH 7.36,contd\n have low urine output 15-20cc/hr,HCT dropped to 23(guaiac neg\n stool)..contd have loose bm .\n ROS:Neuro:alert and oriented x3,as per the pt\nshe has sores all over\n the body\n.CVS:sinus rythum in 80\ns sbp 100-120\ns.Resp:lungs\n clear,diminished at base.on RA satting 95-98%,GI:abd\n soft,bs+ve,mushroom cath draining yellow liquid stool.GU:foley draining\n yellow urine.SKIN:intact.\n Allergies:PCN.\n Precautions:contact(,C DIFF).\n Access:RT IJ, RT 20g.\n .\n Diarrhea\n Assessment:\n Abd soft +ve bowel sounds,denied abd pain but has gen body\n pain\nmushroom cath draining yellow loose stool, As per the pt she had\n ongoing issue of diarrhea for the last few months.\n Action:\n Stool has been sent for cx and infectious work up.contd na\n @120cc/hr,orthostatic VS were obtained.\n Response:\n Stool neg for c diff and ova and parasites,final work up pending.\n Plan:\n Plan for GI consult and possible colonoscopy after the preliminary work\n up,will cont the mushroom cath for now.\n .H/O acidosis, Metabolic\n Assessment:\n Upon arrival to MICU pt Ph was 7.18 in the ED. Pt appears visibly\n dry. With marked electrolyte imbalance.,received biacarb GTT\n overnight\n Action:\n Contd NS @120cc/hr. received 2gm of mgso4\n Response:\n UOP still 15-20cc/hr,ph improved to 7.36,\n Plan:\n Renal involved, follow fluid balance and labs.\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 571561, "text": "This is a 62 year old female with Hep C, CRI who presents with weakness\n admitted to the ICU for metabolic acidosis. She states that since\n yesterday, she has felt \"soreness all over\" particularly in shoulders,\n back and chest as well as abdominal pain. She also reports some nausea\n but denies vomiting. She states that she has had copius diarrhea,\n >30BM's daily, which has been present for months since she C.diff\n diagnosis. She reports mild intermittent non-productive cough. She\n endorses chills, but no overt fever she is being R/O for the flu. Pt\n was sent to the MICU to try and correct her metabolic acidosis.\n ICU COURSE:pt received bicarb in the MICU,rpt abd shows PH 7.36,contd\n have low urine output 15-20cc/hr,HCT dropped to 23(guaiac neg\n stool)..contd have loose bm .Flu has been ruled out.\n ROS:Neuro:alert and oriented x3,as per the pt\nshe has sores all over\n the body\n.CVS:sinus rythum in 80\ns sbp 100-120\ns.Resp:lungs\n clear,diminished at base.on RA satting 95-98%,GI:abd\n soft,bs+ve,mushroom cath draining yellow liquid stool.GU:foley draining\n yellow urine.SKIN:intact.\n Allergies:PCN.\n Precautions:contact(,C DIFF).\n Access:RT IJ, RT 20g.\n .\n Diarrhea\n Assessment:\n Abd soft +ve bowel sounds,denied abd pain but has gen body\n pain\nmushroom cath draining yellow loose stool, As per the pt she had\n ongoing issue of diarrhea for the last few months.\n Action:\n Stool has been sent for cx and infectious work up.contd na\n @120cc/hr,orthostatic VS were obtained.\n Response:\n Stool neg for c diff and ova and parasites,final work up pending.\n Plan:\n Plan for GI consult and possible colonoscopy after the preliminary work\n up,will cont the mushroom cath for now.\n .H/O acidosis, Metabolic\n Assessment:\n Upon arrival to MICU pt Ph was 7.18 in the ED. Pt appears visibly\n dry. With marked electrolyte imbalance.,received biacarb GTT\n overnight,s.cr 2.6.\n Action:\n Contd NS @120cc/hr. received 2gm of mgso4\n Response:\n UOP still 15-20cc/hr,ph improved to 7.36.bicarb improved to 19.\n Plan:\n Renal involved, follow fluid balance and labs.\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 571562, "text": "Patient was seen, examined and case discussed with the ICU resident. I\n agree with their assessment and plan. Please see my note detailing the\n plan bellow.\n Chief Complaint: presents with weakness and metabolic acidosis.\n HPI: 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n She reports copious diarrhea no abdominal pain.\n She is also reporting bilateral shoulder pain right greater than left\n that is associated with movement and deep breaths. This has been worse\n over the last week.\n 24 Hour Events:\n Fluids 1L with bicarb and normal saline started.\n MULTI LUMEN - START 08:00 PM\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n cacitriol\n folic acid\n trazedone\n hep Sq tid\n zophran\n tramadol\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:Diarrhea and shoulder pain\n Flowsheet Data as of 09:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.2\n HR: 80 (71 - 90) bpm\n BP: 98/51(62) {91/46(59) - 142/78(92)} mmHg\n RR: 13 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,565 mL\n PO:\n 200 mL\n TF:\n IVF:\n 480 mL\n 1,365 mL\n Blood products:\n Total out:\n 270 mL\n 165 mL\n Urine:\n 270 mL\n 165 mL\n NG:\n Stool:\n 400cc since am\n Drains:\n Balance:\n 210 mL\n 1,400 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.36/30/81./19/-6\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD\n HEENT; moist MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: CTA bilaterally\n ABD: soft, NT, ND, +BS\n EXT: wasted, no gross motor or sensory deficits\n Labs / Radiology: CT abdomen unremarkable, chest x-ray negative per\n report\n 9.4 g/dL\n 142 K/uL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n 07:44 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n 18\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Lactic Acid:0.7\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Lipase-normal in past.\n Ua-small leuk few bacteria 7WBC PH 5.5\n Cr. 80, Na 68, K 27, Urine osm 310 Urine gap-49 TTKG-4.8\n C.Diff neg .\n Hx \n HIV neg \n Assessment and Plan\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n # Metabolic acidosis: Non-gap metabolic acidosis\n - IVF with bicarb, will volume replete with NS then start oral bicitra.\n - will check orthostatics if orthostatic will give more NS\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear , secretory, secondary to etoh, infectious,\n or osmotic.\n - stool studies and c.diff\n - Send stool osms and fecal fat\n -Consider pancreatic insufficiency\n -If preliminary workup is negative will consult GI\n -D\nc antibiotics\n #Fatigue/shoulder and back pain-getting ruled out for flu very low\n suspicion presented with cough, myalgia started in the ED once DFA\n negative will stop given low suspicion.\n -Unclear etiology of myalgia\n -Normal CK\n -Will observe\n #Acute on chronic renal insufficiency - improved\n -Will need renal follow up.\n - obtain urine lytes\n - IVF\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n #Hx LLL nodule - Repeat chest CT recommended for .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition :Floor.\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2184-06-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 571570, "text": "This is a 62 year old female with Hep C, CRI who presents with weakness\n admitted to the ICU for metabolic acidosis. She states that since\n yesterday, she has felt \"soreness all over\" particularly in shoulders,\n back and chest as well as abdominal pain. She also reports some nausea\n but denies vomiting. She states that she has had copius diarrhea,\n >30BM's daily, which has been present for months since she C.diff\n diagnosis. She reports mild intermittent non-productive cough. She\n endorses chills, but no overt fever she is being R/O for the flu. Pt\n was sent to the MICU to try and correct her metabolic acidosis.\n ICU COURSE:pt received bicarb in the MICU,rpt abd shows PH 7.36,contd\n have low urine output 15-20cc/hr,HCT dropped to 23(guaiac neg\n stool)..contd have loose bm .Flu has been ruled out.\n ROS:Neuro:alert and oriented x3,as per the pt\nshe has sores all over\n the body\n.CVS:sinus rythum in 80\ns sbp 100-120\ns.Resp:lungs\n clear,diminished at base.on RA satting 95-98%,GI:abd\n soft,bs+ve,mushroom cath draining yellow liquid stool.GU:foley draining\n yellow urine.SKIN:intact.\n Allergies:PCN.\n Precautions:contact(,C DIFF).\n Access:RT IJ, RT 20g.\n .\n Diarrhea\n Assessment:\n Abd soft +ve bowel sounds,denied abd pain but has gen body\n pain\nmushroom cath draining yellow loose stool, As per the pt she had\n ongoing issue of diarrhea for the last few months.\n Action:\n Stool has been sent for cx and infectious work up.contd na\n @120cc/hr,orthostatic VS were obtained.\n Response:\n Stool neg for c diff and ova and parasites,final work up pending.\n Plan:\n Plan for GI consult and possible colonoscopy after the preliminary work\n up,will cont the mushroom cath for now.\n .H/O acidosis, Metabolic\n Assessment:\n Upon arrival to MICU pt Ph was 7.18 in the ED. Pt appears visibly\n dry. With marked electrolyte imbalance.,received biacarb GTT\n overnight,s.cr 2.6.\n Action:\n Contd NS @120cc/hr. received 2gm of mgso4\n Response:\n UOP still 15-20cc/hr,ph improved to 7.36.bicarb improved to 19.\n Plan:\n Renal involved, follow fluid balance and labs.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n WEAKNESS\n Code status:\n Height:\n Admission weight:\n 50.3 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Precautions:\n PMH: ETOH, Renal Failure, Smoker\n CV-PMH:\n Additional history: Pt stated she has a problem unclear as to\n what her condition is. Pt also stated she has HEP C.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:57\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,515 mL\n 24h total out:\n 730 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 04:06 AM\n Potassium:\n 3.9 mEq/L\n 04:06 AM\n Chloride:\n 106 mEq/L\n 04:06 AM\n CO2:\n 19 mEq/L\n 04:06 AM\n BUN:\n 23 mg/dL\n 04:06 AM\n Creatinine:\n 2.6 mg/dL\n 04:06 AM\n Glucose:\n 78 mg/dL\n 04:06 AM\n Hematocrit:\n 23.9 %\n 10:54 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 7\n Transferred to: cc 712\n Date & time of Transfer: 1600 hrs\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 571525, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 08:00 PM\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.2\n HR: 80 (71 - 90) bpm\n BP: 98/51(62) {91/46(59) - 142/78(92)} mmHg\n RR: 13 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,565 mL\n PO:\n 200 mL\n TF:\n IVF:\n 480 mL\n 1,365 mL\n Blood products:\n Total out:\n 270 mL\n 165 mL\n Urine:\n 270 mL\n 165 mL\n NG:\n Stool:\n Drains:\n Balance:\n 210 mL\n 1,400 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.36/30/81./19/-6\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 142 K/uL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n 07:44 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n 18\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Lactic Acid:0.7\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n DIARRHEA\n .H/O ABDOMINAL COMPARTMENT SYNDROME / INTRAABDOMINAL HYPERTENSION\n (IAH, ACS)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ACIDOSIS, METABOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 571529, "text": "Chief Complaint: presents with weakness and metabolic acidosis.\n HPI: 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n Per report copious diarrhea.\n 24 Hour Events:\n Fluids 1L with bicarb and normal saline started.\n MULTI LUMEN - START 08:00 PM\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n cacitriol\n folic acid\n trazedone\n hep Sq tid\n zophran\n tramadol\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.2\n HR: 80 (71 - 90) bpm\n BP: 98/51(62) {91/46(59) - 142/78(92)} mmHg\n RR: 13 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,565 mL\n PO:\n 200 mL\n TF:\n IVF:\n 480 mL\n 1,365 mL\n Blood products:\n Total out:\n 270 mL\n 165 mL\n Urine:\n 270 mL\n 165 mL\n NG:\n Stool:\n 400cc since am\n Drains:\n Balance:\n 210 mL\n 1,400 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.36/30/81./19/-6\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no angiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology: CT abdomen unremarkable, chest x-ray negative per\n report\n 9.4 g/dL\n 142 K/uL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n 07:44 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n 18\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Lactic Acid:0.7\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Lipase-normal in past.\n Ua-small leuk few bacteria 7WBC PH 5.5\n Cr. 80, Na 68, K 27, Urine osm 310 Urine gap-49 TTKG-4.8\n C.Diff neg .\n Hx VRE\n HIV neg \n Assessment and Plan\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Non-gap metabolic acidosis\n - IVF with bicarb, will volume replete with NS then start oral bicitra.\n - will check orthostatics if orthostatic will give more NS\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear , secretory, secondary to etoh, infectious,\n or osmotic.\n - stool studies and c.diff\n - Send stool osms and fecal fat\n -Consider pancreatic insufficiency\n -If preliminary workup is negative will consult GI\n -D\nc antibiotics\n #Fatigue-getting ruled out for flu very low suspicion presented with\n cough, myalgia started in the ED once DFA negative will stop given low\n suspicion.\n #Acute on chronic renal insufficiency - improved\n -Will need renal follow up.\n - obtain urine lytes\n - IVF\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or\n portal hypertension. HIV and HBV viral loads were negative.\n #Hx LLL nodule - Repeat chest CT recommended for .\n #Polysubstance abuse -\n - thiamine, folate, MVI\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition :Floor.\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2184-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 571531, "text": "Chief Complaint: weakness\n 24 Hour Events:\n MULTI LUMEN - START 08:00 PM\n - received IVF fluids with bicarbonate, then started on NS\n - repeat ABG improved pH now 7.3\n 7.36 / 30 / 82\n - K down to 3.8\n - Hct drop 6pts\n - loose stool output, ~400cc this morning\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 82 (71 - 90) bpm\n BP: 97/47(59) {91/46(59) - 142/78(92)} mmHg\n RR: 14 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 480 mL\n 1,117 mL\n PO:\n TF:\n IVF:\n 480 mL\n 1,117 mL\n Blood products:\n Total out:\n 270 mL\n 130 mL\n Urine:\n 270 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 210 mL\n 987 mL\n Respiratory support\n SpO2: 97%\n ABG: 7.30/28/49/19/-10\n Physical Examination\n GEN: chronically ill appear woman,older than stated age, in NAD who\n does not appear acutely ill\n HEENT; dry MM, no JVD, no LAD, right IJ in place\n CVS: RRR, no MRG\n PULM: occ exp wheezes\n ABD: soft, diffusely mildly tender\n less tender with distraction, no\n \ns sign, no rebound, NABS, no ascites\n EXT: wasted, strength 5/5 on coaching, no joing swelling, no joing\n erythema, diffusely tender to palpation across shoulders, chest and\n back, no angiomata, no palmar erythema, no petechia, no distal lesions\n Labs / Radiology\n Urine anion gap: 49\n Urine pH: 5.5\n TTKG: 4.8\n CT Abdomen - No acute abnormalities.\n 142 K/uL\n 9.4 g/dL\n 78 mg/dL\n 2.6 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 106 mEq/L\n 132 mEq/L\n 28.3 %\n 7.8 K/uL\n [image002.jpg]\n 01:15 AM\n 04:06 AM\n WBC\n 7.8\n Hct\n 28.3\n Plt\n 142\n Cr\n 2.6\n TCO2\n 14\n Glucose\n 78\n Other labs: ALT / AST:45/51, Alk Phos / T Bili:139/0.4, Ca++:7.5 mg/dL,\n Mg++:1.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n DIARRHEA\n .H/O ABDOMINAL COMPARTMENT SYNDROME / INTRAABDOMINAL HYPERTENSION\n (IAH, ACS)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ACIDOSIS, METABOLIC\n 62 yo F with hep C, substance abuse who presents with metabolic\n acidosis, diarrhea and renal failure.\n .\n # Metabolic acidosis: Improving after IVF with bicarbonate. Non-gap\n metabolic acidosis with inadequate respiratory compensation, nl cl.\n Bicarbonate appears to be chronically low at around 15; however, given\n severely low pH there may be an acute component. On admission one week\n ago, presented with bicarbonate of 13 and was discharged at 19. She has\n also received PO bicarbonate supplementation in the past. Etiology is\n likely diarrhea and renal failure. However, mineralocorticoid can also\n present as low bicarbonate and high K. Improving now on repeat ABG\n after IVF. Urine lytes as above.\n - check orthostatics, if still orthostatic, cont IVF: NS, consider\n change to LR if becoming hyperchloremic\n .\n # Diarrhea: Has had c.diff in the past, but has also had intermittent\n diarrhea of unclear . This diarrhea appears to be chronic and\n profuse, possibly contributing to severe recurrent acid base\n disturbaces. C.diff neg x1 now.\n - check stool studies and c.diff, also w/u for chronic diarrhea\n - may need GI consult for possible endoscopy\n .\n # Weakness/ Soreness: Unclear etiology at this time although chronic\n diarrhea is a possible etiology vs viral illness vs flu. her current\n presentation seems to be c/w prior admissions for abd pain and FTT;\n however, she has also had serious illness in the past. Currently, she\n appears stable w/o fever and with nl BP, mentating well. Ruled out for\n flu by DFA. UA negative.\n - f/u blood cx, stool studies\n - tramadol for pain\n .\n #Acute on chronic renal insufficiency - Baseline cr 1.8, now 3.2.\n patient has had multiple episodes of ARF in the setting of acute\n illness and sepsis this year. On past admissions, she has required\n bicarb supplementation. Improving towards baseline now, although likely\n still has a component of pre-renal.\n - check orthostatics, if still orthostatic, cont IVF: NS, consider\n change to LR if becoming hyperchloremic\n - renal consult\n .\n # Hx Hepatitis C - Genotype 1, HCV viral load 8,720 IU/mL. No clinical\n stigmata or radiographic evidence of cirrhosis or portal hypertension.\n HIV and HBV viral loads were negative.\n - f/u HCV VL\n .\n # Hx LLL nodule - Repeat chest CT recommended for .\n .\n # Polysubstance abuse -\n - thiamine, folate, MVI\n - follow CIWA\n .\n #) Prophylaxis: sc heparin\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: no indication\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "ECG", "chartdate": "2184-06-13 00:00:00.000", "description": "Report", "row_id": 296751, "text": "Sinus rhythm. Right precordial lead/anterior T wave changes. Modestly prominent\nU waves are seen. Borderline prolonged/upper limits of normal QTc interval.\nFindings are non-specific but clinical correlation is suggested for possible\ndrug/electrolyte/metabolic effect. Since the previous tracing of ] the\nrate is slower, QTc interval appears longer, T wave changes are less prominent\nand U waves appear more prominent.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2119-10-28 00:00:00.000", "description": "Report", "row_id": 1505004, "text": "focus hemodynmics\ndata: neuro: on propofol 25mcg/kg/min. gtt off x3 for neuro exam. pt's moves arms on the bed and moves left leg. right leg has cast on it. perla# 3 and reacts briskly. postive gag reflex.\n\nresp: suctioned for thick white sputum. breath sounds course and rhonchi heard throughout lung fields. fio2 decreased to 50% abg 7.45-32-137-23. recruitment breath given tonite. pleural effusion via chest xray. temp 101.3-101.9 tylenol given. cultured, urine, sputum blood via central line and peripherally.\n\ncardiac: on levophed 0.264mcg. k 3.6 and repletedd with 20meqkcl iv. magnesium 1.7 and repleted with 2gms of magnesium sulfate.hct 26.2. dr aware.\n\ngu: foley patent and draining amber colored urine. wgt up today.\n\ngI abd soft to touch. fecal bag applied for lg amt of stool. tube fdgs at 20cc/hr. via j tube . g tube to gravity. pigtail catheter in place and to gravity. draining tan foul smelling drainage. jp draining tan drainage.\n\naction: suctioned prn. labs as ordered. temp >101 tylenol given with culture of blood , sputu and urine. levophed for bp support. propofol gtt and off for neuro assessment. tube fdgs at 20cc/hr. hct 26.2 and wbc 24.\n\nresp: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-28 00:00:00.000", "description": "Report", "row_id": 1505005, "text": "CONDITION UPDATE\nVSS. CONT TO BE TACHYCARDIC: STANDING IV LOPRESSOR DOSE W/ EFFECT. CONT TO BE FEBRILE. TMAX 102.7 - DR. AWARE. CONT TO REQUIRE LEVO TO MAINTAIN SBP MD'S ORDERS. REMAINS ON PPF DRIP. AT TIMES AROUSEABLE TO VOICE. OPENS EYES TO VOICE. PUPILS EQUAL AND BRISKLY REACTIVE. DOES NOT FOLLOW COMMANDS. INCONSISTENTLY W/DRAWS EXTREMITIES TO PAIN. RARELY DEMONSTRATES SPONTANEOUS MOVEMENT. LUNGS COARSE THROUGHOUT. MIN SUCTIONING FOR THICK WHITE SPUTUM. O2SATS ACCEPTABLE ON CURRENT VENT SETTINGS. NO VENT CHANGES THIS SHIFT. ABD OBESE. POSITIVE BOWEL SOUNDS. INCISION C/D - SUTURES INTACT. MOD AMT OF BROWN LIQUID DRAINAGE FROM PIGTAIL DRAIN. SM AMT REDDISH/BROWN DRAINAGE FROM JP. LG AMT LIQUID STOOL OUT FIB. MOD AMT OF GREEN DRAINAGE FROM GT. TOLERATING TFEED AS ORDERED VIA JTUBE. RATE INCREASED TO 30CC/HR. STARTED ON INSULIN DRIP MD'S ORDERS. BSUGARS LABILE. PRESENTLY INSULIN OFF FOR LOW BSUGAR. PT VERY EDEMATOUS. DR. NOTIFIED OF HEMODYNAMIC STATE, PT OVER 1.8L POSITIVE. NOTIFIED OF POSSIBLE NEED TO EXPAND FOOT CAST. U/O QS VIA FOLEY.\nCONT TO MONITOR FOR S/S OF WORSENING INFECTION. DIABETIC MANAGEMENT. STRICT I/O'S. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-26 00:00:00.000", "description": "Report", "row_id": 1504997, "text": "Resp care; Pt remains intubated via #8 ETT rotated and secured 23cm at lip. Bs coarse bilat. Not req freq sx by Rt. periods of Tachycardia/ tachypnea. Sedation optimized by nsg w/ gd effect. ABG WNL w/ hyperoxia. No vent changes made this shift per team. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-26 00:00:00.000", "description": "Report", "row_id": 1504998, "text": "STATUS\nD: FEBRILE..REMAINS ON LEVO & PROPOFOL GTT'S..AROUSABLE TO STIMULI BUT DOESN'T FOLLOW COMMANDS..MOVES ALL EXTREM'S\nA: MULTILUMIN PLACED RT SUBCLAVIAN & LF SUBCLAVIAN DC'D..TIP SENT FOR CULTURE..PAN CULTURED..DROPPING BP>>LEVO INCREASED TO .2MGM..PROPOFOL REMAINS @ 15MCG..CARDIAC ECHO DONE..ADQUATE HUO'S..NO STOOLS..TF'S REMAIN @ 20CC..G TUBE DRAINING MOD AMT BILIOUS..NO VENT CHANGES SUCTIONED FOR MOD AMT THIN WHITE..JP DRAINING PURULENT SM AMT\nR: SEPSIS\nP: AWAITING CULTURE RESULTS..CONTINUE TX'S AS ORDERED\n" }, { "category": "Nursing/other", "chartdate": "2119-10-27 00:00:00.000", "description": "Report", "row_id": 1504999, "text": "Nursing note\nNEURO: PROPOFOL @ 25MCG/KG, TURNED OFF FOR NEURO EXAM-OPENS EYES TO VOICE, NOT OBEYING COMMANDS, MOVES ALL EXTREM'S, RLL CASTED, GRIMACES TO PAIN STIM, POS CORNEALS, 3MM BILAT/BRISK, MEDICATED PRN MORPHINE 2MG FOR PAIN\n\nRESP: POS GAG, SXN FOR MIN WHITE-THICK SECRETIONS, BREATHING OVER VENT ON AC-CHANGED TO SIMV THIS AM, 12 PEEP, 10 PS, AM ABG'S REFLECT RESP ALK\n\nCARDIO: LEVOPHED @ 0.254MCG/KG, MAP MAINTAINED >65,CVP 8-11, T-MAX 102- GIVEN TIMES 2,PRESENTLY 101.2, SINUS TACHY, OCCAS PAC'S\n\nABD: HYPO BS, GT WITH 275CC GRN BILIOUS DRNG, JT WITH TF @ 20, NO RESID-PATENT TO FLUSH, ABD DSG D&I\n\nINTEG: LEFT ANKLE ABRASION WITH MIN S/S DRNG-COV'D WITH DSD, ALL OTHER ABRASIONS D&I, ABLE TO INSERT 1FINGER INSIDE TOE END OF CAST, TOES WARM\n\nPLAN: WEAN LEVO WHEN POSSIBLE, MAINTAIN MAP>65, WEAN FROM VENT, ASSESS NEURO THROUGHOUT SHIFT\n" }, { "category": "Nursing/other", "chartdate": "2119-10-27 00:00:00.000", "description": "Report", "row_id": 1505000, "text": "resp care\nPt initially on a/c but changed to imv 430x22 40% 12peep and 10psv with peak/plat 24/20.Bs coarse bil. ABG revealed a resp alkalosis. Will cont to follow and wean peep and rr as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-27 00:00:00.000", "description": "Report", "row_id": 1505001, "text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICUA x 2 without incident.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-27 00:00:00.000", "description": "Report", "row_id": 1505002, "text": "STATUS\nD: REMAINS ON LEVO & PROPOFOL GTT'S..FEBRILE..WBC'S CLIMBING..NO CULTURES BACK YET\nA: CHEST & ABD CT DONE..SHOWED ABCESS & PLEURAL EFFUSION..DROPPING SAT'S WITH STIMULATION..REQUIRING INCREASE IN FIO2 TO 60% & PEEP 15..SUCTIONED FOR SM AMT THIN WHITE..LUNG SOUNDS COARSE WITH RALES DECREASED IN RT BASE..RETURNED TO CT FOR PLACEMENT OF RT PIGTAIL DRAIN DRAINING TAN..SPEC SENT FOR CULT/AMYLASE/BILI..SAT'S/ABG'S CONTINUE TO DROP WITH STIMULATION..INCT LIQ BROWN STOOL..FIB PLACED..JP DRAINING TAN..GT DRAINING BILIOUS..JT TOL TF'S @ 20CC/H..ADQUATE HUO\nR: SEPTIC WITH WORSENING ARDS\nP: ? LATER TONITE OR OVER WEEK-END..? TAP EFFUSION..CONTINUE TO MONITOR ABG'S/SAT'S/LYTES..AWAITING CULTURE RESULTS\n" }, { "category": "Nursing/other", "chartdate": "2119-10-28 00:00:00.000", "description": "Report", "row_id": 1505003, "text": "Respiratory Care\nPt.remains on full vent.support.Recruitment manuever done earlier this shift md order.oxygenation improved t/o night.fio2 decreased to .50 abg's reveal very good oxygenation s/p change.Suctioned for moderate amounts of thick white secretions.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-25 00:00:00.000", "description": "Report", "row_id": 1504991, "text": "Respiratory Care:\nMorning abg results revealed a compensated respiratory alkalemia with excellent oxygenation. FIO2 decreased from 50% to 40%. Remains on A/C ventilatory support (see CareVue).\n\nNo RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-25 00:00:00.000", "description": "Report", "row_id": 1504992, "text": "data: febrile 101.8-101-tylenol and cool bath but not able to break fever. hr-90's down to low 80's after lopressor. weaned levo slowly\nfrom .25mcg/kg/min to .20mcg/kg/min. transfused 1upc for hct 28-post hct 30. cvp 11-14. huo 30-50cc.\npt not following commands but grimaces to pain w/ activity. sedated on ppf 40mcg/kg/min and prn morphine/ativan.\nabd. softly distended-no bowel sounds present. incision c&d. gt draining thick dk green bilious. small amt tan color fliud for jp.\ntube fdg @ 10cc 2/3str impact.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-10-25 00:00:00.000", "description": "Report", "row_id": 1504993, "text": "Resp Care\n\nPt remains intubated and on full vent support. RR decreased to 22 but pt maintaining a mv between 12-15L. ABG 7.42/28/93/19. BS clear and suctioning thick white in small amts\n" }, { "category": "Nursing/other", "chartdate": "2119-10-25 00:00:00.000", "description": "Report", "row_id": 1504994, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB/ASSESSMENTS.\nCONTINUES TO BE FEBRILE, WILL CULTURE IF SPIKES GREATER THAN 102.9.\nON COOLING BLANKET AND TYLENOL GIVEN--STARTING TO COME DOWN.\nSLOWLY WENAING LEVO, BUT DIFFICULT WITH PERSISTANT FEVER. PROPOFOL DOWN TO 10 MCG/KG, WILL SUPPLEMENT SEDATION WITH PRN MSO4/ATIVAN AS NEEDED. URINE OUTPUT CONTINUES TO BE ADEQUATE, LR REMAINS AT 80CC HR AND PATIENT CONTINUES TO BE + IN I/O WITH WEIGHT INCREASING EVERY DAY.\nREMAINS ON A/C, RATE DROPPED THIS AM, YET PERSISTANTLY OVERBREATING TO CORRECT FOR NORMAL pH. NO FURTHER GASES DONE TODAY.\nNO COMMUNICATION FROM FAMILY.,\nTUBE FEEDS ADVANCE, SKIN REMAIN INTACT, NO BREAKDOWN.\nTEAM AWARE OF ABOVE, WILL CALL WITH ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-26 00:00:00.000", "description": "Report", "row_id": 1504995, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick pl yellow secretions. Sedated with propofol. Getting levophed. Temp 99.8. ABG'S good. Plan to wean down peep.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-26 00:00:00.000", "description": "Report", "row_id": 1504996, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nLightly sedated on propofol and supplemented with ativan and morphine for pain control. Grimaces with movement, and morphine given with good effect.\n\nREmains on vent with no changes made over night. Stable ABG on peep of 12. Sat's >98%. Breath sounds clear and equal bilaterally.\n\nCV: SR with occ PAC noted. Levophed titrated up and down tonight to maintain Mean BP 70. 12 beat run of SVT this am that resolved on own. Resident Dr. updated.\n\nAbd remains softly distended with hypoactive bs. Tube feedings, 2/3 strength impact with fiber at 20cc/ hour. Gtube to gravity draining dark bilious color. JP drain with tan color drainage, specimen sent for amylase and bilirubin. No stool thus far.\n\nGU: foley to gravity, clear yellow >30cc/hour.\n\nSocial: No contact from family overnight.\n\nPLan: Cont to follow glucose and cover RISS. Treat temp with tylenol and cooling blanket prn, Culture if TMax >102.3. To remain on 12 PEEP / ARDS protocol. Maintain Mean BP >70 wean Levophed as tolerated. Wean sedation/ propofol as tolerated supplement with Ativan and manage postop pain with morphine. D/C plan is ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-24 00:00:00.000", "description": "Report", "row_id": 1504988, "text": "Condition update\nD: pt is alert and follows commands. moves all extremities. medicated with morphine for pain and ativan for agitation with good relief. pt remains wrist restrained due to self extubation yesterday. pt started on propofol titrated to 20mcgs/kg/min. for sedation after desatting to the 80's. pt comfortable on currentl settings and resp rate is 19.\ncardiac: nsr to st rate in the 90's - 114. sbp greater than 100 and levophed weaned to .15mcg/kg/min. cvp is . pt remains on lopressor q4.\nresp: pt desatting to the 80's. resp rate in the mid 20's. breath sounds remain coarse and diminished in the bases. pt suctioned for thick white sputum.\na: fio2 increased to 70% and peep increased to 8. pt started on propofol for sedation.\nr: pt continues to desat to the low 90's. pt suctioned for minimal white sputum.\na: peep increased to 12 and cxr done.\nr: cxr unchanged per sicu resident. repeat abg with po2 up to 150.\na: attempt to decrease fi2 to 60% with drop in o2 sat ot the low 90's. pt suctioned for scant white sputum and pt increased back to 70%.\ngi: pt remains npo and jtube clamped and gtube to gravity.\ngu: urine output remains adequate. pt prehydrated for ampho dose.\nid: pt started on amphp iv with premed and test dose. pt tolerated 1mg test dose without problem. pt tolerated remainder of dose with no reaction. temp max 100.4.\nskin: pt with abrasions on head and legs and arms. no drainage noted abrasions remain open to air.\na: continue to monitor labs. aggressive pulmonary toilet. ? bronchoscopy today.\nr: pt requiring more vent support. very sensitive to vent changes. to tolerated. ampho dose. morphine effective in relieving pain. pt comfortable on the vent on 20mgs/kg/min of propofol.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-24 00:00:00.000", "description": "Report", "row_id": 1504989, "text": "Resp Care\n\nPt remains intubated and vented on A/C with changes made accordingly. BS essentially clear sxing for minimal secretions. Last ABG WNL with acceptable oxygenation. Will cont to wean PEEP as tol. ETT secured/patent. Heated wire placed for better humidification. WIll cont with vent support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-24 00:00:00.000", "description": "Report", "row_id": 1504990, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/ASSESSMENT/LAB INFORMATION.\nPATIENT REMAINS SEPTIC, WITH INCREASING LEVO REQUIREMENTS AS WELL AS FLUID REQUIREMENTS. UNABLE TO WEAN LEVO LOWER THAN .15 MCG/KG, AND CURRENTLY ON .25 WITH FLUID RUNNING AS UNABLE TO REALLY GET SBP>100 MOST OF THE SHIFT.\nNGT OUT, TROPHIC TUBE FEEDS BEGUN VIA JTUBE AT 10CC HRS. JP REMAINS IN TO SELF SUCTION, DRAINING SMALL AMOUNT OF TAN DRAINAGE, SENT FOR BILI AND AMYLASE THIS AM.\nSEDATED ON PROPOFOL, DOES MOVE EXTREMITIES TO PAIN, PUPILS EQUAL AND REACTIVE. ALSO MEDICATED DURING THE DAY WITH PRN MS04 AND ATIVAN.\nVERY TACHY CARDIC THIS AM--TEAM AWARE, TREATED WITH SLOWLY INCREASING SEDATION AS TOLERATED, GIVING FLUID, GIVING LOW DOSE LOPRESSOR AS ORDERED. ?EKG CHANGES ON 12 LEAD, RULE OUT PROTOCOL IN PLACE.\nRESP--BEGUN ON ARDS PROTOCOL WITH WEIGHT BASED TIDAL VOLUMES AND HIGHER RATES. IMPROVED ABGS, AND FIO2 WEANED FROM .70 TO .5 AND PEEP TO 10 FROM 12. HAS TOLERTED CHANGES WELL, CURRENTLY PO2 73 ON 10 OF PEEP, TO INCREASED BACK TO 12 PER HO.\nSKIN INTACT, BLOOD SUGARS CONTROLLED ON SLIDING SCALE.\nTUBE FEEDS BEGUN AT 10CC HR. VIA JTUBE.\nNO CALL FROM FAMILY TODAY.\nP: PATIENT CONTINUES WITH SEPTIC PICTURE.\nCONTINUE TO SUPPORT WITH LEVO/FLUID.\nMONITOR I/O, CHECK LYTES AS ORDERED.\nHO AND TEAM AWARE OF ABOVE. WILL CALL WITH ANY CHANGES.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-10-23 00:00:00.000", "description": "Report", "row_id": 1504982, "text": "ASSESSMENT AS NOTED\n\nRES: ON A/C DOWN TO 70%, WAS IN MET ACIDOSIS LAST NIGHT POST OP AND AS PUT ON BICARB GTT, BY 2 AM PH CORRECTED >7.40 LS COARSE WITH SM AMNT THICK CLEAR SPUTUM, WEAK COUGH\n\nCV:ON LEVOPHED TO KEEP SBP>100(SEE CAREVUE), IV BOLUS GIVEN AND GETTING EXTRA IVF IN FORM OF PIGGIBAGS, CVP WAVEFORM IS DAMPED, R ARM EDEMA,WEAK PULSES, FAIR U/O 70-120/H, DIPS BP WHEN GIVEN LOPRESSOR WITH HR DOWN TO 90S\n\nGI: G-TUVE TO GRAVITY DRAINS DARK BILE SM AMNT, NO B.S. YET, NOTHING IN NGT, J-TUBE CLAMPED\n\nSKIN: ABD DRESSING HAS SM BLOOD SPOT ON, SMALL ABRASIONS ON BOTH FEET, CAST ON R FOOT\n\nNEURO: WEAK, NO SEDATION GIVEN, PAIN MNGMNT WITH MORPHINE, OPENS EYES TO VOICE, FOLLOWS SIMPLE COMMANDS\n\nID: SPIKED >102 DESPITE HE IS ONVANCO, FLAGYL, FLUC AND LEVOFLOX, H/O AWARE , TREATED WITH TYLENOL\n\nENDO/LABS: K, CA , MAG REPLETED, RISS IN USE\n\nPLAN: MONITOR ID, METHABOLIC\n" }, { "category": "Nursing/other", "chartdate": "2119-10-23 00:00:00.000", "description": "Report", "row_id": 1504983, "text": "ADENDUM TO NOTE\nPLAN : ? TO EXTUBATE, D/C NGT , GIVE 2 FFP TO CORRECT INR AND VIT K. FOR 3 DAYS\n" }, { "category": "Nursing/other", "chartdate": "2119-10-23 00:00:00.000", "description": "Report", "row_id": 1504984, "text": "Respiratory Care\nPt remained intubated overnight on a/c mode. ABGs initially with metabolic acidosis, now corrected. Pt is overbreathing the vent up into high 20s at times. FIO2 weaned down to 60% with only marginal PaO2.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-23 00:00:00.000", "description": "Report", "row_id": 1504985, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 15/5 tol well with vt around 400-500cc and RR in the mid dto low 30s. BS essentially clear sxing for minimal amts of white secretions. ETT secured/patent. Last ABG WNL with good oxygenation. Will cont to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-23 00:00:00.000", "description": "Report", "row_id": 1504986, "text": "nursing note\nNeuro: nods yes/no , follows commands. medicated with morphine with adequate relief.\nCV:ST-remians on lopressor. hypotensive -remians on levo, attempts to wean unsucccessful with BP to 80 sys. CVP 9-14. lasix x1 with extubation.\nRESP:self extubated while restrained, reintubated secondary to increased work of breathing. suctiond for scant white secretions.\nGI:NPO. GT with bilious output and NGT with bilious output.\nGU:foley patent adeq urine.\nSKIN:multiple bruises-son states from old falls, cast intact, toes warm.\nSOCIAL;son in to visit-expressing appro concerns regarding plan of care.\n\nPLAN:cont resp wean as tol, medicate with ativan/morphine prn. await return of gi funxtion.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-24 00:00:00.000", "description": "Report", "row_id": 1504987, "text": "Respiratory Care:\nPatient's SPO2 plummeted early in the shift. Both the FIO2 and the PEEP were increased (the FIO2 was increased to 70% and the PEEP was increased first to 8 cm and then to 12 cm). A recruitment maneuver was performed (see CareVue). Morning abg results revealed a compensated respiratory alkalemia with excellent oxygenation. The FIO2 was lowered from 70% to 60%, at which time the SPO2 decreased from 99% to 91%. FIO2 was returned to 70% and the SPO2 rebounded to 98%.\n\nNo RSBI measured due to the level of PEEP and FIO2 required.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-03 00:00:00.000", "description": "Report", "row_id": 1505023, "text": "SEE CAREVIEW FOR DETAILS\nFOCUS DATA UPDATE\n\n\nNEURO: MEDICATED WITH MORPHINE AND , FOR COMFORT, ABLE TO FOLLOW COMMANDS INTERMITTENLTY, MAE'S, PERLA\n\nRESP: VENT SETTINGS UNCHANGED, SX BOTH ETT AND ORALLY FOR THICK WHITE SECRETIONS, BITING ON ETT, BITE BLOCK PUT IN PLACE FOR SAFETY\n\nCV: MAP > 60, HR NSR, NO ECTOPY NOTED, TOL IV ABX'S, LYTE REPLACEMENT, T MAX 100.9 AX, TYLENOL GIVEN, VIA J-TUBE,\n\nGI: G-TUBE GRAVITY, J-TUBE TOL TF @ GOAL DECREASED TO 10/HR PER DR. , ABDOMENAL ABCESS DRAIN PATENT, WOUND OPEN TO VAC DRESSING FOR SEROUS SANGERNOUS DRAINAGE INSULIN GTT ADJUSTED ACCORDING TO SCALE Q1H, TOL IVP LASIX, IVP LOPRESSOR HELD X1 FOR HYPOTENSION\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: CONTINUE TO ATTEMPT TO WEAN FROM VENT, OOB TO CHAIR CONTINUE EMOTIONAL AND EDUCATIONAL SUPPORT TO BOTH PATIENT AND FAMILY\n\nGI\n" }, { "category": "Nursing/other", "chartdate": "2119-11-03 00:00:00.000", "description": "Report", "row_id": 1505024, "text": "Resp. care note - Pt. remaines intubated and vented, PS weaned to 5 cm H2O tol ok. at this time.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-03 00:00:00.000", "description": "Report", "row_id": 1505025, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, NODDING APPROPRIATELY IN RESPONSE TO QUESTIONS, MAE. C/O PAIN THROUGHOUT THE DAY, MORPHINE IV GIVEN WITH GOOD EFFECT. GIVEN A FEW TIMES, PT APPEARS AGITATED, BE DUE TO CONFUSION (NODDED \"NO\" TO \"DO YOU KNOW WHERE YOU ARE?\")\nCV- BP STABLE, RISING TO 140'S WHEN AGITATED, MAP ABOVE 60 ALL SHIFT. HR 80-90'S WITH OCCASIONAL PVCS, NSR. LOPRESSOR IV GIVEN AS SCHEDULED WITH SLIGHT DECREASE IN BP AND HR.\nRESP- LUNGS CLEAR, VENT DECREASED TO CPAP 5/5 AND PT TOLERATING WELL WITH ABG WNL, WILL CONTINUE TO MONITOR FOR LABORED BREATHING.\nGI/GU- ABD SOFT, VAC DRESSING INTACT AND DRAINING LARGE AMOUNTS OF SEROSANG. TUBEFEEDS REMAIN ONLY TROPHIC FOR NOW. LARGE AMOUNTS OF UOP FOLLOWING SCHEDULED LASIX, CVP 1-3, CURRENTLY 2.5 L NEG.\nID- TEMP 101.4 THIS AM, TYLENOL GIVEN, DR. NOTIFIED.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-04 00:00:00.000", "description": "Report", "row_id": 1505026, "text": " 23/07\n NEURO ALERT OPEN EYES TO COMANDS MAE IMITATION CASTED LEG BECAUSE OF WT RELAXED OCC C/O PAIN FULL RELAXATION AS A RESULT\n RESP CLEAR GOOD COUGH ON VENT CPAP 5/5 WEANING O2 TOL WELL\n HEART S1S2 ST OCC RUNS OF PAT SELF LIMITED MD\nPULSES NOTED\n GI POS HYPOACTIVE IN NATURE TOL T/F WELL FIRM ABD\n CASTED RIGHT LEG IN PLACE SPLIT\n PLAN SUPPORTIVE CARE\n" }, { "category": "Nursing/other", "chartdate": "2119-11-04 00:00:00.000", "description": "Report", "row_id": 1505027, "text": "Resp Care\nPt remains on vent. Intubated with #8 ett @ 23, patent and secure. Suctioned small amt of thick yellow secretions. Abgs WNL. Tirated fio2. Plan to extubate in the morning.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-29 00:00:00.000", "description": "Report", "row_id": 1505006, "text": "Respiratory Care\nPt.remains on full vent.support.Abg's adequate on current settings.suctioned for moderate amounts of thick white secretions.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-29 00:00:00.000", "description": "Report", "row_id": 1505007, "text": "focus hemodynmics\ndata: neuro: on propofol gtt. off for neuro assessement. opens eyes spontanously. sticks tongue out to command. diffficulty moving extremities due to edematous limbs. perla and # and reacts briskly. hands restrained and order in poe.\n\nresp: remains intubated and suctioned for thick white sputum. o2sats 99-100%. breath sounds course. abg 7.42-30-122-20. temp 100.3-102.4 tylenol given. cooling blanket applied. wbc 27.1\n\ncardiac: remains on the levophed gtt and weaning slowly. magnesium , potassium and calicium values repleted. hct 25 and 1unit prbc given lasix 20mg iv given with good diuresis. post hct 28.0.\n\ngI: abd soft. fecal bag intact and draining brown liquid stool. tube fdgs infusing and rate increased to 40cc/hr. jp tube draining tan drainage. pigtail drain draining tan drainage with pus balls present in the tubing. wbc count 27.1.\n\ngu: foley patent and draining amber colored urine.\n\naction: suctioned prn. labs as ordered. on iv vanco, merepenum and flagyl. tube fdgs rate increased to 40cc/hr. insulin gtt on/off blood sugar q1hr. levophed gtt weaning slowly. propofol gtt on at 25mcg/kg/min. opens eyes to name. moves arms on the bed. k ,mag and calicium repleted.\n\nrespnse: monitor closdly\n" }, { "category": "Nursing/other", "chartdate": "2119-10-29 00:00:00.000", "description": "Report", "row_id": 1505008, "text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to SICUA without incident.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-02 00:00:00.000", "description": "Report", "row_id": 1505019, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results determined a normal acid-base balance with excellent oxygenation.\n\nNo RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-29 00:00:00.000", "description": "Report", "row_id": 1505009, "text": "CONDITION UPDATE\nVSS. REMAINS ON LEVO TO MAINTAIN BP PER ORDERED PARAMETERS. PAN CULTURED FOR CONT. FEVERS. LOW TEMP OF 100.1. SEDATED ON PPF. AROUSEABLE TO VOICE. AT TIMES FOLLOWS SIMPLE COMMANDS. AT TIMES MOVES EXTREMITIES TO COMMAND. VENT CHANGED TO CPAP PREVIOUS SHIFT. REPEAT ABG ACCEPTABLE. O2SATS ACCEPTABLE. LUNGS COARSE THROUGHOUT, OCC SUCTIONING FOR THICK, WHITE SPUTUM. ABD SOFT, OBESE. POSITIVE BOWEL SOUNDS. STAT CTSCAN ORDERED AND DONE, QUESTION LEAK. MD - NO LEAK NOTED. GTUBE REMAINS TO DRAINAGE. JTUBE W/ STR IMPACT AT 20CC/HR. CONT ON INCULIN GTTS. BSUGARS LABILE. PIGTAIL PATENT - YELLOW/BROWN DRAINAGE OUT. JP W/ COPIOUS AMTS OF BILIOUS DRAINAGE - TXPLANT TEAM NOTIFIED. NO NEW ORDERS. LG AMT OF LIQUID STOOL VIA FIB BAG. ORTHO CONSULT DONE. RFOOT FILMS OBTAINED. CAST EXPANDED (CUT) TO PREVENT DAMAGE FROM INCREASED BODY EDEMA.\nCONT TO MONITOR FOR WORSENING INFECTION. WEAN FROM VENT AS TOLERATES. STRICT I/O'S. F/U CULTURE RESULTS. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-30 00:00:00.000", "description": "Report", "row_id": 1505010, "text": "Respiratory Care\nPt.remains on PSV,no vent.changes this shift.Abg's adequate.Suctioned for moderate mucoid secretions.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-02 00:00:00.000", "description": "Report", "row_id": 1505020, "text": "SICU nursing progress note\nPLease refer to flowsheet for specific info. and events.\n\nNeuro: Alert at times and following commands inconsistently.\n\nResp: Breath sounds clear and /= bilaterally. Suctioning white thick secretions through ETT. Sat's > 99% with within normal limits acid base balance.\n\nCV: SR with occasional Pac's noted. Lopressor 5mg IV q 6 hours for rate control. On Levophed currently at .02 mcg/kg/min. Wean to off for MAP >60 and adequate UOP.\n\nGI/ Abd: TF of impact with fiber at 10cc/hour with no advancement. Hypoactive bowel sounds. BRown loose stool noted with FIB in place.\n(+) culture for C. Diff. Abdominal midline surgical site draining copious amounts of serosanguinous. Dr. in and removed staples. Plan is for vacuum dressing, and CT of abdomen on Friday.\n\nGU/ Lytes: Foley cath to gravity, UOP >50cc/hour. Calcium, potassium within norm. Magnesium replenished.\n\nEndo: Remains on insulin drip with hourly blood sugars.\n\nID: Tmax 101.6, (not cultured)on linezolid, ambizone, meropenum, and flagyl. (+)MRSA, (+)VRE, (+)C. Diff.\n\nPlan: Cont to follow glucose titrate drip to scale, cont antibiotics. Plan is to have vac. drain for abdomen and CT scan on Friday. D/C plan is ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-02 00:00:00.000", "description": "Report", "row_id": 1505021, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT TODAY, FOLLOWING MOST COMMANDS, MAE. NODDING IN RESPONSE TO QUESTIONS, C/O PAIN AND TREATED WELL WITH MORPHINE IV. NO SEDATION TODAY.\nCV- BP STABLE OFF LEVO ALL SHIFT WITH MAP ABOVE 65-70. LASIX GIVEN TWICE THIS SHIFT, ORDERED TID AND PT DIURESING WELL HOWEVER BP DROPPING SLIGHTLY WITH THIS AFTERNOON'S DOSE. HR 80'S-90'S WITHOUT ECTOPY, NSR.\nRESP- LUNGS CLEAR AND SUCTIONED EVERY FEW HOURS FOR THICK WHITISH SPUTUM. ATTEMPTED WEAN TODAY, PT TOLERATING CPAP 5/5 FOR A FEW HOURS WITH NORMAL ABGS. BECAME TACHYPNEIC THIS AFTERNOON AND APPEARED TO BE LABORED, NOW CURRENTLY ON WITH GOOD EFFECT.\nGI/GU- ABD SOFT, ABSENT BS. VAC DRESSING PLACED IN INCISIONAL WOUND BY TEAM, DRAINING LARGE AMOUNTS OF SEROSANG. TOLERATING TF WHICH HAS BEEN ADVANCED TO 30CC/ HR WITH GOAL OF 90CC/HR. UOP AVERAGING 300-400CC/HR WITH CURRENT NEG FLUID BALANCE OF ALMOST 2L.\nID- NO TEMP SPIKES TODAY, REMAINS ON ANTIBIOTICS.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-03 00:00:00.000", "description": "Report", "row_id": 1505022, "text": "Respiratory Care:\nPatient remains on CPAP/PSV with no parameter changes made throughout the night. Morning abg results determined a normal acid-base balance with excellent oxygenation on the current settings. Sx'd for moderate to large amounts of secretions.\n\nRSBI = 65 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-01 00:00:00.000", "description": "Report", "row_id": 1505017, "text": "SICU nursing progress note\nPlease refer to flowsheet for specific info.\n\nNeuro: Awakens to voice, inconsistently following commands. PERRL.\n\nResp; Breath sounds clear to coarse and equal bilaterally. Sat's >98% on current vent settings and acid base balance wnl. ETT suctioned for thick white secretions ~q 2 hours.\n\nCV/ Heme: SR no ectopy. HCT 25 and transfused with one unit PRBC's, post HCT 27. HR 90-110 prior to transfusion. Post transfusion 70-80's. Responds well to IV lopressor q 4 hours/ current dose 7.5mg.\n\nGI/ Abd: Hypoactive bs with promote tube feedings at 10cc/ hour through Jtube. Abd softly distended and obese. Fecal incontinence bag with loose brown stool noted. Gtube draining light green bile color. Pigtail with green bile color drainage. JP drain with dark bile color drainage in large amounts averaging 50- 75cc/hour. Midline Incision with staples intact. Base of incision is opened and wet to dry dressing applied, granulating well.\n\nGu/ lytes: Foley cath to gravity with clear yellow urine. Magnesium replenished. K and Ca wnl.\n\nENdo: on insulin drip and following protocol. Glucose stable.\n\nID: On flagyl, meropenum, linezolid, and ambizone. WBC count down this morning.\n\nPlan: Cont to follow glucose q 1 hour and titrate insulin drip to protocol. Maintain tube feedings at 10cc/ hour. Cont to adm pain and anxiolytics as indicated. Maintain MAP >70 levophed currently off. Replace electrolytes following labs as ordered. Cont to update and support spokesperson. D/C plan is ongoing.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-11-01 00:00:00.000", "description": "Report", "row_id": 1505018, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT OPENING EYES TO VOICE, MAE, NOT FOLLOWING MANY COMMANDS, OCCASIONALLY WILL OPEN MOUTH ON COMMAND. UNABLE TO NOD IN RESPONSE TO QUESTIONS. MORPHINE GIVEN WHEN PT GRIMACING, USUALLY DURING REPOSITIONING, GOOD EFFECT. GIVEN PRN FOR AGITATION.\nCV- BP LABILE, ON AND OFF LEVO THROUGHOUT THE DAY TO KEEP MAP GREATER THAN 70. LOPRESSOR HELD DUE TO LEVO REQUIREMENTS, HR STABLE IN 80'S WITHOUT ECTOPY. LASIX ALSO HELD THIS AM DUE TO DECREASED BP. CURRENTLY NEG BY ABOUT 100CC SINCE MIDNIGHT. I UNIT OF PRBCS GIVEN THIS AM, HALFWAY THROUGH TRANSFUSION, PT BEGAN SHAKING, TEMP WAS 99.6 AT THE TIME. TRANSFUSION STOPPED, REPORTED TO DR. , TYLENOL AND BENADRYL GIVEN, TRANSFUSION REACTION FORM FILLED OUT AND SENT TO BLOOD BANK ALONG WITH THE REST OF THE TRASFUSION. NO OTHER ILL EFFECTS NOTED SINCE.\nRESP- LUNGS CLEAR, STRONG COUGH. SUCTIONED A FEW TIMES FOR THICK WHITE SPUTUM. NO VENT CHANGES MADE.\nGI/GU- ABD SOFT, NO BS HEARD. IMPACT WITH FIBER 1/2 STRENGTH VIA J TUBE. T-TUBE DRAINING BILIOUS LIKE SUBSTANCE, JP ALSO APPEARS TO BE DRAINING BILE, EMPTIED Q1HOUR FOR 80-100CC, TEAM NOTIFIED. FECAL BAG DRAINING SMALL AMOUNT OF LOOSE BROWN STOOL. UOP ADEQUATE, 80-120CC/HR.\nID- TEMP SPIKED TO 101.2 THIS AFTERNOON, DR. NOTIFIED, CHANGE ALL LINES TOMORROW. TYLENOL GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-05 00:00:00.000", "description": "Report", "row_id": 1505033, "text": " 15/07\n PT ALERT SOMEWHAT COFUSED AT TIMES PROGRESSIVE LESS CONFUSED THRU SHIFT MAE IN GOOD SPIRITS NO RESTRAINTS NEEDED\n RESP CLEAR OCC SOB RE POSITIONING DECREASES RESP EFFORT 4 L NP TOL WELL\n HEART S1S2 ST OCC RUN PAT NARROW COMPLEX SELF LIMITED PULSES POS THREE FAIR CIR TO CASTED RIGHT LEG VSS\n ABD FIRM POS B/S STOOLING DRAINS IN PLACE J/P LG AMOUNTS MD AWARE PLEASE SEE CAREVIEW FOR DETAILS\n PLAN OOB TO CHAIR SUPORTIVE EMOTIONAL CARE PT OT DETOX MONITOR FOR D/T POSSIBLE DELAYED APPEARANCE\n" }, { "category": "Nursing/other", "chartdate": "2119-11-06 00:00:00.000", "description": "Report", "row_id": 1505034, "text": "NURSING NOTE\nNEURO: ALERT, ORIENTED TO PERSON AND YEAR, THINKS HE'S IN NY, STATES YEARS WHEN ASKED TO NAME MONTH, OBEYS COMMANDS, MOVES ALL EXTREMS,\nMORPHINE GIVEN FOR ABD AND R FOOT PAIN\n\nCVS: HR 90S-110S, NSR, OCCASIONAL TACHY, SBP 120S-130S, LASIX 20MG GIVEN X 1, LOPRESSOR 5MG X 2, T MAX 100.1,\n\nRESP: O2 SATS 96-98, LUNGS SLIGHTLY DIMINISHED AT BASES, OTHERWISE CLEAR\n\nABD: MIDLINE WND VAC INTACT, TF TO JT-NO RESIDUAL, GT DRNG GRN BILIOUS TO SM AMTS, JP DRNG GREENISH BILIOUS FLUID TO MOD AMTS, PIGTAIL WITH SM AMT MILKY BRN DRNG\n\nPLAN: PAIN CONTROL, ANTIBIOTICS, DRNG CARE, NUTRITIONAL SUPPORT, GLUCOSE MONITORING, WND CARE, LIKELY TRANSFER TO FLOOR TOMORROW\n" }, { "category": "Nursing/other", "chartdate": "2119-11-07 00:00:00.000", "description": "Report", "row_id": 1505035, "text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE. C/O R ANKLE PAIN WHICH IS RELIEVED BY MORPHINE PRN. CAST R FOOT INTACT.\n\nLUNGS BILAT CLEAR. SATS 96-100% ON ROOM AIR.\n\nTOLERATING TUBE FEEDS VIA J TUBE. NO OUTPUT VIA G-TUBE. ABD WOUND WITH VAC DRESSING INTACT-MINIMAL LIGHT SEROSANG OUTPUT. JP WITH LARGE AMOUNTS SEROSANG OUTPUT. T-TUBE WITH CLOUDY LIGHT BROWN MUCOUS DRAINAGE WHICH APPEARS MORE SEROSANG THIS AM.\n\nADEQUATE URINE OUTPUT.\n\nPLAN:\nTRANSER TO FLOOR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-10-22 00:00:00.000", "description": "Report", "row_id": 1504981, "text": "ADMIT NOTE\n\nPT ADM FROM HOSP VIA AMBULANCE,\n\nNEURO: VAGUE, MAE'S, C/O ABD PAIN, MEDICATED WITH MORPHINE 4MG'S IVP,\n\nRESP: O2 2L/M VIA, NC BS CLEAR DIMINISHED @ BASES B/L,\n\nCV: A-LINE INSERTED, RIGHT SUBCLAVIAN CONVERTED TO SWAN, LABS PENDING TYPE AND CROSS NS WIDE OPEN\n\nGI: ABD TENDER\n\nGI: BUN/CRT ELEVATED URINE AMBER\n\nA/P: DUODENAL PERFERATION DESTINATION OR\n" }, { "category": "Nursing/other", "chartdate": "2119-10-31 00:00:00.000", "description": "Report", "row_id": 1505013, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT, FOLLOWING COMMANDS, REMAINS OFF PROPOFOL, REQUIRING SM DOSES OF MORPHINE FOR PAIN CONTROL.\nCV: T MAX 101- NOT CX'D PER PRIMARY TEAM. TACHYCARDIC AT TIMES TO 112- RESOLVES AFTER Q4HR LOPRESSOR GIVEN. LEVO WEANED TO OFF WITH MAP >70. HCT DOWN TO 25.2 THIS AM\nRESP: NO VENT CHANGES THIS TONIGHT. BS CLEAR BUT DIMINISHED IN BASES. SX FOR SM AMTS THIN WHITE SECRETIONS Q2-3HRS\nGI: ABD SOFTLY DISTENDED WITH + BS. TF CHANGED TO 1/2 ST IMPACT WITH FIBER AT 10CC VIA JT. GT TO GRAVITY WITH SM AMT BILIOUS DRAINAGE. JP CONT TO DRAIN COPIOUS AMTS OF CLEAR YELLOW TO BILIOUS DRAINAGE. TPN CONT.\nGU: CLEAR AMBER URINE IN GOOD AMTS, NO LASIX GIVEN\nENDO: INSULIN GTT TITRATED AS , PRESENTLY ON 7 UNITS/HR\nSKIN: ABD INCISION CLEAN AND DRY- DSD APPLIED, MULT SM ABRASIONS ON LE- CLEAN AND DRY WITH SCAB FORMATION PRESENT. RLE CAST INTACT.\nA: HEMODYNMICS AND RESP PARAMETERS MONITORED, LEVO TITRATED TO OFF KEEPING MAP>70, INSULIN GTT TITRATED PER .\nR/ POC: ? DIURESIS TODAY IF LEVO REMAINS OFF, ? WEAN FROM VENT AS TOLERATED, CONT TO MONITOR BS Q1HR AND TITRATE GTT AS PER PROTOCOL, MEDICATE FOR PAIN AS INDICATED\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-10-31 00:00:00.000", "description": "Report", "row_id": 1505014, "text": "resp care\nPt remained on psv10/peep10 with volumes of 500cc and rr 24-30. Min volume cocsistently 12-14l. BS clear. RSBI not done due to inc peep level. Morning abg revealed a compensated met acidosis. Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2119-10-31 00:00:00.000", "description": "Report", "row_id": 1505015, "text": "Neuro alert not following commands, mae, pupils equal and reactive. Given 1-2mg IV prn and mso4 1-2mg IV prn for anxiety and pain with good effect\nCVS HR 115-92 st to nsr without ectopy bp map > 70 dropped to 63 restarted levophed at .01mcg/kg/min at 1900 skin w and diaphoretic pp lt foot +2, hct 25, lopressor increased to 7.5mg IV q 4\nresp cpap +PS 50/500-580/12 peep ps 10 7.40/32/130/21/- lungs clear diminished bases sx sm amt thin white secretions\nGI JP output bilious 770 gastric tube 45cc greenish pigtail 100cc abd obese BS present early then absent team aware, incision c+d team took out several staples packed with NS w-d. Fecal bag in place sm amt brown liq stool\ngu u/o > 30cc qhr given lasix 10mg ivp mn to 1800 neg 1312\nendo on insulin gtt, tpn\nOrtho in changed rt ankle cast\nID temp max 101.8 tylenol given antibx given\na. s/p roux-y gastrojeg, plyoric exclusion, closure duod perf \n+MRSA, +VRE, GPC, +GNR, +PMN septic\np. wean levophed as tol to keep map > 70\ngive lopressor as ordered may need to decrease dose again\nmonitor hct\nempty JP q 1-2 hrs attempt to get bigger JP from OR\nmonitor temp tylenol as ordered antibx as ordered maintian contact precautions\nBS q 1 hr follow protocol pt now has insulin in tpn\n\n" }, { "category": "Nursing/other", "chartdate": "2119-11-01 00:00:00.000", "description": "Report", "row_id": 1505016, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes throughout the night. Morning abg results determined a normal acid-base balance with good oxygenation on the current settings.\n\nNo RSBI measured due to the levle of PEEP required.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-04 00:00:00.000", "description": "Report", "row_id": 1505028, "text": "Sicu nursing Progress Notes\nEvents: Given gastrographin for abd CT, Vent settings continue on PSV 5/peep 5, large loose stool.\n\nCardiac: B/P 110-148/50's, HR 85-105.\n\nResp: Remains on vent at PSV 5/Peep 5, FiO2 40%. Suctioned x3 for small to mod amount of white secretions. 1130 he started to C/O being SOB with his rr increasing from 22-24 to 40's. He was suctioned for very little. ABG 7.42/36/81. He fell asleep soon after the ABG and his RR returned to the 20's. Plan is to decrease vent settings to 0/0 but no plan for extubation.\n\nGI: Tube feenings of Impact with fiber infusing at 10cc/hr. He was given 30cc gastrographin mixed in 900cc water from 930 to 1130. He went for abd CT at 1430. He had a huge loose brown stool at 1130, his rectal bag came off and was reapplied.\n\nGU: Foley draining clear yellow urine. U/O 100-125cc/hr. He received routine dose of lasix 20mg at 11am with his U/O increasing to ~300cc/hr.\n\nNeuro: He is recieving no sedation, he is awake and alert. He following command inconsistantly. He is very restless in the bed requiring frequent repositioning. His cast remains intact with good pulses.\n\nID: Temp 100.0-100.6. He is receiving linezolid, flagyl, and meropenem. His JP drain is draining alot of serosang drainage, site looks intact.\n\nSocial: no contact with the family.\n\nPlan: Upon return from CT scan drop vent settings to Psv 0/Peep 0 for a trial, continue to monitor I&O, suction PRN.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-04 00:00:00.000", "description": "Report", "row_id": 1505029, "text": "Resp. care note - Pt. remains intubated and vente transffered to CT and back to SICUA without incident.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-04 00:00:00.000", "description": "Report", "row_id": 1505030, "text": " 15/07\n NEURO IMPROVING ALERT SMILES MAE WELL WITH PURPOSE SLEEPS SHORT PERIODS NO PAIN AT THIS POINT\n RESP STABLE CPAP 5/5 TOL WELL NO ISSUES WILL TOL REMOVAL OF ETT SCANT SPUTUM\n HEART S1S2 NO ISSUES NSR TO ST PULSES POS 3 THRU OUT\n ABD LG SOFT TUBES IN PLACE WENT TO ABD CT THIS PM TOL WELL LG BM S POS NORMAL B/S STOOLS SOFT IN NATURE PLEASE CAREVIEW FOR DETAILS\n PLAN ETT OUT OOB TO CHAIR PROGRESSIVE AMBULATION WITH STRONG PT/OT RESOURSE\n" }, { "category": "Nursing/other", "chartdate": "2119-11-05 00:00:00.000", "description": "Report", "row_id": 1505031, "text": "Resp Care\nPt remains on vent. No changes made. Suctioned small amt of thick yellow secretions. Plan to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2119-11-05 00:00:00.000", "description": "Report", "row_id": 1505032, "text": "Nursing note (0700-1500) 13:15\n\nNeuro.\nPt alert, but confused as to time and place, believes he is in , and that he is leaving for hospital soon, Pt reoriented as able, wrist restraints remain in place as pt tried to get up at one stage.\nDenies pain, moving all limbs with normal power.\n\nResp.\nExtubated this am, very good abg on 4l nc, LS clear to all fields.\n\nCVS.\nHR 80's NSR with rare ectopy, BP stable via a-line, MAP 90-100.\n\nGI/GU.\nTrophic feeds continue, G-tube draining large amounts of green bilious liquid. +BS with moderate amount of drainage via mushroom cath of brown liquid stool.\nFoley patent, with good response to IV lasix dose.\n\nSkin.\nIntact pressure areas, incisions dry + intact.\n\nSocial.\nNo calls or contact as yet this shift.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-10-30 00:00:00.000", "description": "Report", "row_id": 1505011, "text": "Nursing progress note\nNeuro:Propofol off and pt is awake, alert, following simple commands, PERRLA. Lorazepam given as ordered for anxiousness related to ET-Tube discomfort. Morphine Sulfate 1 mg IVP x 2 for\n generalized discomfort.\n\nCV: SR to ST with rare PACs, metoprolol 5mg IVP q6hrs given wit decrease in HR to 70's initially.\n\nResp: Pt remained on CPAP with PS10 and PEEP 12. ABGs PH 7.41 PCO2-33,\n PO2-75, TCO2-22 BE-2, oximeter sat 95% at time of blood gas draw. O2sat has been 98% most of night. ET-tube suctioned for thin white secretions in moderate am'ts. ET-Tube discomfort relieved with PRN MS .\n\nGI/Abd:Abd CT with duodenal leak as of Sunday . JP LUQ draining\n large am,ts of bilious fluid from this site, emptied q 1hr.\n GT to BSD draining green liquid containing contrast. trophic TFs to jejunostomy tube at 20ml/hr do not increase.Abd large tender to touch esp LLQ. Primary team aware. Bile drain draining small am't of tenacious bile colored fluid to BSD.\n TPN infusing via CL at 42ml/hr. FIB in place draining thick liq stool in moderate am'ts.\n\nRenal: 2 way foley to urimeter draining clear amber urine 60ish per hr. BUN Creat 27 and 0.7. pt -650 at 12am. Now -250. Wgt up today but pt is in new bed.\n\nHeme: Hct27.9, WBC 22.8. C-Diff stool culture sent.\n\nSkin: Intact Blister noted .5 x.5 cm right flank. OTA.\n\nPlan: Probable Bronch today\n ? CVL change -new TPN as of Sun.\n may start vanco via TB to cover C-Diff\n Give lorazepam and Morphine PRN for et-tube and generalized discomfort.\n Wean norepi- keep MAP>70.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-10-30 00:00:00.000", "description": "Report", "row_id": 1505012, "text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nNeuro: Pt is awake and alert, following all commands. TMax 100. Moves all extremities. Upper ext. edematous. son called to check status and will be in to visit this evening.\n\nCV/GU: BP to be maintained at a mean >70. Levophed weaning as able. HR stable, 90-100, 70s after lopressor. Urine output adequate 60-80cc/hr amber and clear.\n\nGI: G-tube to gravity. J-tube clamped. TPN. Bowel soft and and present bowel sounds. Pigtail to gravity. JP to bulb sx continues with 60-90cc/hr of green bile. transplant team decided not to readminister JP output via j-tube and j-tube remains clamped per ICU team. FIB intact with only small amount loose brown stool.\nInsulin gtt cont to be titrated as needed. monitor pt's lytes, insulin, and glucose d/t new tpn orders. ?add insulin to tpn\n\nResp: lungs sound clear to coarse adn diminished in the bases. Continues on CPAP same settings and abg sent this afternoon. Strong cough adn q 2 hour suctioning for thin white secretions.\n\nEmotional support and orientation provided. Please refer to carevue for details.\n" }, { "category": "Echo", "chartdate": "2119-10-26 00:00:00.000", "description": "Report", "row_id": 80616, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 264\nBSA (m2): 2.35 m2\nBP (mm Hg): 106/62\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 11:16\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV cavity size. Hyperdynamic LVEF. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. The left ventricular cavity size is normal. Left ventricular\nsystolic function is hyperdynamic (EF 70-80%). Right ventricular chamber size\nand free wall motion are normal. The ascending aorta is mildly dilated. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no pericardial\neffusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-11-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 894614, "text": " 8:45 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p r picc\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap w/ sepsis, ARDS requiring\n abx\n REASON FOR THIS EXAMINATION:\n s/p r picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old with ARDS and sepsis, now with new right-sided PICC\n placement.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH: There has been removal of a central venous\n right-sided catheter. There is a new right-sided PICC line with tip overlying\n the cavoatrial junction. No evidence of pneumothorax. Cardiomediastinal\n silhouette is stable. Lungs are clear. Right costophrenic angle is not fully\n evaluated on this examination. Bibasilar linear atelectasis.\n\n IMPRESSION:\n\n 1) Right-sided PICC line with tip in the cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-11-16 00:00:00.000", "description": "CT GUIDANCE DRAINAGE", "row_id": 894073, "text": " 11:39 AM\n CT GUIDANCE DRAINAGE; CT FINE NEEDLE ASP Clip # \n CT GUIDED NEEDLE PLACTMENT; CT ABDOMEN W/O CONTRAST\n CT PELVIS W/O CONTRAST\n Reason: please drain right retroperitoneum fluid collection\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p gastro-jejunostomy s/p repair of duodenal ulcer/perforation\n REASON FOR THIS EXAMINATION:\n please drain right retroperitoneum fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE.\n\n INDICATION: Patient with history of collection post-biliary leak. The\n patient's drain is in situ, but recent CT suggests a persistent fluid. For\n evaluation.\n\n TECHNIQUE: Informed consent was obtained from the patient. Pre-procedure\n timeout was performed to confirm patient identity and indication for\n examination.\n\n The patient was consented for a possible exchange or insertion of a new\n catheter.\n\n REPORT: A pre-procedure CT showed that the original catheter was within the\n collection but located marginally. Although this could be aspirated,\n repositioning of this catheter with the aid of a wire was not possible. Hence,\n a decision was taken to insert a new catheter. A new spot was marked and an\n 8-French catheter was inserted using a trocar technique. The catheter\n was secured into position. Approximately 100 mL of purulent fluid was\n aspirated.\n\n CONCLUSION: Successful CT-guided drainage. The attending, Dr. , was\n present and assisted throughout.\n\n" }, { "category": "Radiology", "chartdate": "2119-11-15 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 893908, "text": " 11:11 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please evaluate for fluid collections, acute processesPlease\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p Roux en Y gastrojej, repair of duodenal perforation,\n G/J tube placement.\n REASON FOR THIS EXAMINATION:\n please evaluate for fluid collections, acute processesPlease have test\n performed with both IV and PO contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 56-year-old man status post Roux-en-Y gastrojejunostomy, and\n repair of duodenal perforation. Status post gastrostomy tube placement, and\n placement of the pigtail drain into a complex retroperitoneal fluid\n collection.\n\n COMPARISONS: , and .\n\n TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with 150\n cc of intravenous Optiray, as well as oral contrast. Sagittal and coronal\n reformats were also performed.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is persistent, but much improved\n bibasilar atelectasis, and the previously noted bilateral pleural effusions\n have essentially resolved. There are two subcentimeter hypoattenuating foci\n in the right lobe of the liver, which are too small to characterize, but are\n unchanged. The patient is status post Roux-en-Y gastrojejunostomy. There is\n a gastrostomy tube terminating in the stomach.\n\n There is a surgical drain terminating in the resection bed, with air, most\n likely related to the presence of the drain. The post-surgical appearance of\n the stomach, small and large bowel, is unremarkable.\n\n Prominent periportal lymph nodes are again noted, the largest measuring 25 x\n 14 mm in axial dimensions. The pancreas, spleen, adrenal glands are within\n normal limits. There are small sub-5 cm hypoattenuating foci in the kidneys,\n which are too small to characterize, but most likely represent simple cysts\n and are unchanged.\n\n There is a similar overall appearance of complex retroperitoneal fluid\n collection which involves the anterior and posterior pararenal spaces on the\n right, and tracks downward into the presacral space. A pigtail drain\n terminates along the lateral edge of the collection in the right posterior\n pararenal space.\n\n CT OF THE PELVIS WITH IV CONTRAST: In addition to the fluid collection, which\n is surrounded by a thin enhancing wall, tracking into the presacral space,\n behind the rectum, from the right, again noted, also is a second fluid\n (Over)\n\n 11:11 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please evaluate for fluid collections, acute processesPlease\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n collection anterior to the bladder, also with an enhancing wall, which is\n similar in size and appearance.\n\n There is air in the bladder, which can be seen in recent Foley\n catheterization. There is fluid in the rectum, but no definite communication\n with the posterior fluid collection. The sigmoid and rectum are unremarkable.\n There is no pelvic or inguinal lymphadenopathy or free fluid.\n\n BONE WINDOWS: There are suspicious lytic or blastic lesions. Again noted is\n an L1 compression fracture.\n\n IMPRESSION:\n\n 1. No significant interval change in the appearance of the complex\n retroperitoneal fluid collection, involving the anterior and posterior\n pararenal spaces, as well as a connection to fluid collection in the presacral\n space in the pelvis.\n\n 2. Fluid collection anterior to the bladder, as well, with a similar\n appearance.\n\n 3. Continued improvement in the appearance of the colon.\n\n 4. Reduced pleural effusions. Also improvement in ascites.\n\n\n" }, { "category": "ECG", "chartdate": "2119-11-10 00:00:00.000", "description": "Report", "row_id": 204985, "text": "Sinus rhythm. Left axis deviation. Early precordial R wave progression\nsuggestive of right ventricular hypertrophy or posterior myocardial infarction.\nNo previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2119-10-29 00:00:00.000", "description": "RP FOOT AP,LAT & OBL RIGHT PORT", "row_id": 891781, "text": " 10:44 AM\n FOOT AP,LAT & OBL RIGHT PORT Clip # \n Reason: f/u xray\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with right foot fracture s/p casting\n REASON FOR THIS EXAMINATION:\n f/u xray\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FOOT ON AT 11:56\n\n INDICATION: Right foot fracture .\n\n COMPARISONS: There are none on PACS.\n\n FINDINGS: As visualized through casting material, it is difficult to find the\n fracture site. I suspect it may be at the proximal aspect of the first\n metatarsal. No old films were available. These could be scanned in to PACS\n for comparison. Regardless there is no misalignment and the fragments should\n be in good apposition due to the inapparent nature on these films. Incidental\n note is made of degenerative changes at the MTP joint of the first digit.\n\n" }, { "category": "Radiology", "chartdate": "2119-11-08 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 893119, "text": " 3:21 PM\n ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: interval change in fx, identification of site based on filsm\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hypoglycemic ground level falls\n REASON FOR THIS EXAMINATION:\n interval change in fx, identification of site based on filsm from \n ______________________________________________________________________________\n FINAL REPORT\n THREE VIEWS OF THE RIGHT ANKLE\n\n INDICATION: Status post closed reduction of ankle fracture.\n\n FINDINGS: Cast overlies the right ankle which obscures fine bony detail.\n Persistent fracture lucency is seen through the distal fibula; however, it\n appears somewhat less distinct on the current exam as compared with , . There is osseous demineralization, and dorsal spurs projecting from\n the talus. No new fracture identified.\n\n" }, { "category": "Radiology", "chartdate": "2119-10-29 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 891794, "text": " 1:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: EVALUATE FOR DUODENAL STUMP LEAK, REPAIR OF DUODENAL PERFORATION, GJ TUBE, ELEVATED BILI, ELEVATED AMYLASE\n Admitting Diagnosis: GI BLEED\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p Roux en Y gastrojej, repair of duodenal perforation, G/J\n tube.\n REASON FOR THIS EXAMINATION:\n evaluate for duodenal stump leak (Elevated bili/elevated amylase) Please place\n 150 cc contrast through JTube, 50 cc via Gtube just prior to the study).\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Abdominopelvic CT.\n\n HISTORY: 56-year-old woman SP Roux-en-Y gastrojejunostomy, repair of duodenal\n perforation, GJ tube, evaluate for duodenal stump leak (elevated amylase).\n\n Comparison is made to prior study dated .\n\n ABDOMEN CT: In the limited images obtained throughout the bases of the lungs,\n there are unchanged bilateral pleural effusions with adjacent subsegment\n consolidations.\n\n The liver, spleen, pancreas, adrenals and kidneys are unremarkable.\n\n GJ tube in place. There is no extravasation of the contrast media. Multiple\n surgical clips are seen in the right upper quadrant. There has been mild\n interval increase in the amount of the ascites. Drainage catheter is again\n seen in place adjacent to the liver.\n\n There has been interval placement of pigtail catheter in a right\n retroperitoneal collection that shows interval decrease in size, with fluid\n content and pockets of gas within.\n\n The aorta is normal in caliber.\n\n Unchanged mild bowel wall thickening of the colon.\n\n PELVIC CT: The bladder is collapsed with Foley catheter and bowel loops in\n its lumen. Important quantity of free fluid. There is unchanged wall\n thickening of the sigmoid colon.\n\n BONE WINDOWS: There are no concerning bone lesions. Mild degenerative\n changes are seen throughout the spine. There is a compression fracture in the\n vertebral body of L1. There are no concerning bone lesions.\n\n IMPRESSION:\n 1. Interval increase in the large amount of free fluid throughout the abdomen\n and pelvis.\n (Over)\n\n 1:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: EVALUATE FOR DUODENAL STUMP LEAK, REPAIR OF DUODENAL PERFORATION, GJ TUBE, ELEVATED BILI, ELEVATED AMYLASE\n Admitting Diagnosis: GI BLEED\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Interval decrease in size in the right retroperitoneal collection with\n pigtail catheter in place.\n 3. Mild generalized bowel wall thickening of the colon, unchanged from the\n prior study, there is no pneumatosis.\n 4. Unchanged bilateral pleural effusions with adjacent bilateral subsegmental\n consolidations.\n 5. There is no extravasation of the contrast media.\n\n" }, { "category": "Radiology", "chartdate": "2119-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 894486, "text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrte, effusions\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap w/ sepsis, ARDS\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrte, effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS, evaluate for infiltrate, effusions.\n\n CHEST, SINGLE AP VIEW.\n\n There are low inspiratory volumes, with bibasilar atelectasis. There is a\n right subclavian central line with tip over distal SVC. There is upper zone\n redistribution, but no overt CHF. No frank consolidation or gross effusion is\n identified. Possible minimal blunting of the costophrenic angles. The heart\n is not enlarged. Clips and a drain are faintly seen over the abdomen at the\n periphery of this film.\n\n IMPRESSION: Bibasilar atelectasis and possible minimal costophrenic angle\n blunting. Otherwise, no radiographic evidence of acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-10-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 890906, "text": " 7:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm central line position, ett position\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex-lap\n REASON FOR THIS EXAMINATION:\n confirm central line position, ett position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORT LINE PLACEMENT FROM AT 20:54.\n\n COMPARISON: None.\n\n INDICATION: ET tube is located 4 cm above the carina at the level of the\n clavicles. NG tube extends off the bottom of the film. A left subclavian\n catheter tip overlies the SVC. No pneumothoraces are present. There is a\n right pleural effusion. The lung volumes are low. No focal consolidations\n are present. The heart size is normal. The mediastinal caliber is wide. A\n right PA and lateral would be helpful when the patient's condition improves.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891041, "text": " 5:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap, self extubated - now reintubated\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of perforated duodenal ulcer, status post exploratory\n laparotomy, self-extubated, now intubated.\n\n Comparison is made to the chest x-ray obtained one day prior.\n\n FINDINGS: There is again present an endotracheal tube, which terminates\n satisfactorily in below the level of thoracic inlet. There is also a left-\n sided subclavian central venous catheter, which is in stable position. A\n nasogastric tube is present, which appears to course below the level of the\n diaphragm, although the tip is not well seen. Bilateral pleural effusions are\n again present, left greater than right. There are also bilateral dependent\n and retrocardiac atelectasis/consolidation. Allowing for differences in\n rotation, this is not significantly changed.\n\n" }, { "category": "Radiology", "chartdate": "2119-11-04 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 892642, "text": " 2:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: interval change. please infuse 150cc contrast thru J-tube an\n Admitting Diagnosis: GI BLEED\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p Roux en Y gastrojej, repair of duodenal perforation, G/J\n tube.\n REASON FOR THIS EXAMINATION:\n interval change. please infuse 150cc contrast thru J-tube and 50cc thru g-tube\n prior to scan\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 56-year-old man status post Roux-en-Y gastrojejunostomy for\n repair of duodenal perforation. Gastrostomy tube, jejunostomy tube, surgical\n drain, and the pigtail drainage catheter. Please assess for change in fluid\n collections and interval change.\n\n STUDY: CT abdomen and pelvis with contrast.\n\n TECHNIQUE: Multidetector CT was obtained through the axial plane of the\n abdomen and pelvis after the injection of 50 cc of oral contrast through the\n gastrostomy tube and 150 cc of oral contrast through the jejunostomy tube with\n intravenous contrast given (150 cc Optiray). Five-mm axial images were viewed\n on PACs along with reconstructions in the sagittal and coronal planes at 5-mm\n slice thickness.\n\n COMPARISON: .\n\n FINDINGS:\n\n LUNG BASSES: Bilateral pleural effusions, left greater than right, are not\n significantly changed in size. As before, there is bilateral subsegmental\n consolidation likely reflecting atelectasis. As before, there are mitral\n annular and coronary artery calcifications. Tip of a central venous catheter\n is seen in the distal SVC.\n\n ABDOMEN AND PELVIS CT: The liver, spleen, bilateral adrenal glands, and\n bilateral kidneys are unchanged in appearance and without concerning\n abnormality. There are bilateral subcentimeter low-attenuation lesions within\n each kidney, too small to characterize on this study.\n\n Gastrostomy tube is in expected and unaltered position. Contrast is seen\n within the stomach which has undergone banding within the antrum. No contrast\n is seen distal to this within the stomach or within the duodenum or proximal\n jejunum. There is a small amount of gas adjacent to the surgical drain in the\n region of the duodenum, which is new since the prior study and of dubious\n significance with the drain position nearby. No increase in fluid about the\n duodenum. Jejunostomy tube is seen in expected and unaltered position. The\n small bowel is grossly normal in appearance and contrast has progressed into\n (Over)\n\n 2:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: interval change. please infuse 150cc contrast thru J-tube an\n Admitting Diagnosis: GI BLEED\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the colon.\n\n Colonic wall thickening has decreased since the prior study though there is\n still moderately severe colonic thickening within the cecum, ascending colon,\n descending colon, and portions of the sigmoid colon. The colonic process\n appears to be resolving. There is no pneumatosis within the colonic wall.\n\n The right lateral pigtail catheter lies within the right posterior pararenal\n space fluid collection, which is not definitely smaller in size, though the\n gas within the collection has resolved. Smaller fluid collection along the\n right anterior pararenal space is also not definitely decreased in size.\n Retroperitoneal fluid extending into the pelvis along the right and presacral\n region in unchanged. There is overall less ascites within the abdomen and\n pelvis. Anterior to the urinary bladder and extending along the anterior\n peritoneum, where there was ascites before, there is now a partially organized\n fluid collection that measures roughly 8 x 4.2 x 2 cm.\n\n As before, there is a Foley catheter within place with gas, contrast and fluid\n within the bladder. Bilateral ureters are normal in caliber and contain\n contrast material.\n\n No concerning bone lesions. As before, there is multilevel disc degeneration.\n There is an old compression fracture of the L1 vertebral body.\n\n\n IMPRESSION:\n 1. No contrast leakage from bowel or findings concerning for perforation.\n Small amount of gas adjacent to the right upper quadrant drain is likely\n related to the drain.\n\n 2. No change in size of right posterior pararenal space fluid collection with\n pigtail catheter, or anterior pararenal fluid collection. Both of these\n appear heterogeneous, as does the fluid extending into the pelvis.\n\n 3. Decrease in overall ascites with small partially organized fluid\n collection along the anterior peritoneum within the pelvis.\n\n 4. Decreased wall thickening of the colon with resolution of wall thickening\n in some areas consistent with resolving colonic process. No pneumatosis.\n\n 5. Unchanged pleural effusions and bilateral lower lobe atelectasis.\n\n\n (Over)\n\n 2:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: interval change. please infuse 150cc contrast thru J-tube an\n Admitting Diagnosis: GI BLEED\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2119-10-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 891448, "text": " 11:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement, progression of infiltrate\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap w/ sepsis, ARDS, new RSC line\n REASON FOR THIS EXAMINATION:\n line placement, progression of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n The study is a chest port line placement.\n\n Comparison to .\n\n INDICATION: Perforated duodenal ulcer status post ARDS with new right\n subclavian line.\n\n A tip of a new right subclavian line terminates at the cavoatrial junction. No\n pneumothorax present. ET tube in standard position. A small/moderate right\n pleural effusion is larger than before. There is some bibasilar atelectasis.\n A left subclavian line is unchanged in position over the SVC. Perihilar haze\n and interstitial markings may indicate a small degree of pulmonary edema that\n is relatively unchanged. There are low lung volumes.\n\n IMPRESSION: Successful right subclavian line placement with no pneumothorax.\n Enlarging right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2119-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891099, "text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening?\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap, self extubated - now reintubated\n with worsening oxygenation\n REASON FOR THIS EXAMINATION:\n worsening?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable AP chest.\n\n COMPARISON: To at 2:25\n\n INDICATION: Perforated duodenal ulcer status post ex lap, reintubated with\n worsening oxygenation.\n\n There has been resolution of right upper lobe atelectasis within the interval\n 6 hours suggesting clearing of mucus plug. Tiny right pleural effusion is\n unchanged, left pleural effusion is resolved. There is a tiny amount of\n atelectasis in the left lower lobe. The heart is normal size and mediastinal\n contours are normal. The ET tube and left subclavian catheters are unchanged\n in their position.\n\n" }, { "category": "Radiology", "chartdate": "2119-10-27 00:00:00.000", "description": "CT RETROPERITONEAL DRAINAGE", "row_id": 891618, "text": " 3:33 PM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n CT ABDOMEN W/O CONTRAST\n Reason: please tap right retroperitoneal fluid collection (send for\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p Roux en Y gastrojej, repair of duodenal perforation, G/J\n tube.\n REASON FOR THIS EXAMINATION:\n please tap right retroperitoneal fluid collection (send for Gram stain and\n culture) and place drain if able\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT-guided retroperitoneal drainage.\n\n HISTORY: 56-year-old man with Roux-en-Y gastrojejunostomy, with h/o duodenal\n perforation. Assess for right retroperitoneal fluid collection drainage.\n\n Abdomen CT without contrast confirmed the presence of a large right\n retroperitoneal collection containing gas within it, please refer to complete\n description of abdomen ct findings under \"Abdomen CT dated \"\n\n PROCEDURE: Written informed consent was obtained by the surgical team from\n the patient's son. timeout was called to confirm the identity of\n the patient and the procedure to be performed.\n\n The patient was prepped and draped in the usual sterile fashion. Lidocaine 1%\n was used as local anesthetic.\n\n CT GUIDED DRAINAGE: Under CT fluoro guidance an 8-French pigtail catheter was\n localized and advanced into the right retroperitoneal collection. Aspiration\n yielded 25 cc of bloody material, a sample was sent to analysis\n\n The catheter was secured in place.\n\n There were no complications.\n\n Dr. was present during all portions of the procedure.\n\n IMPRESSION:\n 1. Successful CT-guided drainage of right retroperitoneal collection.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892095, "text": " 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap w/ sepsis, ARDS\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with sepsis, ARDS, assess interval changes.\n\n Portable upright chest radiograph of at 15:35 is compared to\n the prior study of .\n\n Moderate bilateral pleural effusions are unchanged. Cardiac and mediastinal\n contours are stable. There is mild CHF. Previously visualized opacity in the\n right upper lobe has resolved. There is interval improvement in the left\n perihilar opacity. An opacity in the right mid lung zone represents\n atelectasis Vs. aspiration. The tip of the right subclavian catheter projects\n over the SVC. Endotracheal tube is in appropriate position.\n\n IMPRESSION:\n 1. Interval resolution of right upper lobe opacity, interval improvement of\n left perihilar opacity.\n\n 2. Bilateral pleural effusions with mild CHF.\n\n 3. Right middle lung zone opacity, representing atelectasis Vs. aspiration.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891613, "text": " 3:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desats on 100% FiO2\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap w/ sepsis, ARDS\n REASON FOR THIS EXAMINATION:\n desats on 100% FiO2\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable AP chest.\n\n Comparison to AP as well as CT torso from earlier today.\n\n INDICATION: Status post perfed duodenal ulcer with ARDS setting on a 100%\n FiO2.\n\n There is a new opacity in the right upper lobe that is not seen on the supine\n scout from the torso CT earlier today. In addition, there is an ill-defined\n left perihilar opacity. Given the rapid change, an acute process such as\n aspiration should be considered. Moderate bilateral effusions are unchanged.\n The cardiac silhouette and mediastinal contours are stable. Tip of a right\n subclavian projects over the SVC. No pneumothorax. The ET tube is 6 cm above\n the carina at the level of the clavicles.\n\n IMPRESSION: New right upper lobe and left perihilar opacities, likely\n due to acute aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2119-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891069, "text": " 2:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: consolidation\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with perf'd du s/p ex lap, self extubated - now reintubated\n with worsening oxygenation\n REASON FOR THIS EXAMINATION:\n consolidation\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Comparison to at 18:07.\n\n INDICATION: Perforated duodenal ulcer status post ex lap, reintubated with\n worsening O2 sat.\n\n FINDINGS: ET tube is located 5 cm above the carina at the level of the\n clavicles. There is a new dense opacity in the right upper lung obscuring the\n mediastinal and apical borders likely representing right upper lobe\n atelectasis/collapsed. Mediastinal hematoma is not favored based on the\n appearance. There is some decrease in left pleural effusion. No\n pneumothoraces are present.\n\n IMPRESSION: Partial right upper lobe atelectasis/collapse.\n\n" }, { "category": "Radiology", "chartdate": "2119-10-27 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 891566, "text": " 10:17 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: source of sepsis. please give 100 cc contrast per J-tube and\n Admitting Diagnosis: GI BLEED\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p Roux en Y gastrojej\n REASON FOR THIS EXAMINATION:\n source of sepsis. please give 100 cc contrast per J-tube and 50 cc per G-tube\n immediatly prior to study\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man status post Roux-en-Y gastrojejunostomy. Please\n evaluate for possible source of sepsis.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT acquired axial images of the chest, abdomen and pelvis were\n obtained with 150 cc of IV Optiray contrast.\n\n CT OF THE CHEST WITH IV CONTRAST: A large right-sided pleural effusion is\n seen. A moderately sized left-sided pleural effusion is seen. The bilateral\n pleural effusions are also associated with atelectasis. The heart and great\n vessels appear unremarkable. Several mediastinal lymph nodes are seen,\n however, none appear pathologically enlarged. Endotracheal tube is seen in\n place in the trachea.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a large amount of ascitic fluid\n seen throughout the abdomen. Fluid is seen in the right and left subphrenic\n regions. There is fluid around the spleen, pancreas, liver, and stomach. The\n fluid collection seen in the right posterior perirenal space appears to have\n some pockets of gas within, concerning for an infected collection. The fluid\n appears to extend down into the pelvis. Loops of bowel are seen within the\n abdomen with thickened wall, likely secondary to the fluid.\n\n Numerous surgical clips are seen within the mesentery. A drain is seen in\n place adjacent to the liver.\n\n CT OF THE PELVIS WITH IV CONTRAST: Free fluid is seen throughout the pelvis.\n There is evidence of fluid in the presacral area, surrounding the sigmoid as\n well as other loops of bowel. There is also evidence of bowel with thickened\n walls within the pelvis, likely secondary to the fluid. Air is seen within\n the bladder, likely secondary to Foley catheterization.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n IMPRESSION:\n 1. Large amount of fluid seen throughout the abdomen extending into the\n pelvis. The fluid in the right posterior perianal space appears to have\n pockets of gas within, concerning for an infected collection. Some bowel wall\n (Over)\n\n 10:17 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: source of sepsis. please give 100 cc contrast per J-tube and\n Admitting Diagnosis: GI BLEED\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n thickening is seen as well, likely secondary to the free fluid.\n\n 2. Bilateral pleural effusions with associated atelectasis, right greater\n than left.\n\n Findings discussed with the surgical team on .\n\n" } ]

[ { "category": "Radiology", "chartdate": "2132-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809267, "text": " 2:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evalaute for CHF\n Admitting Diagnosis: HYPOKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with ? pre-eclampsia\n REASON FOR THIS EXAMINATION:\n evalaute for CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Pre-eclampsia.\n\n Heart size is normal. The lungs are clear. No pleural effusions in this single\n view.\n IMPRESSION: NO abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2132-12-24 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 809287, "text": " 5:08 PM\n CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n Reason: evaluate for intr-abdominal bleed\n Admitting Diagnosis: HYPOKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman PPD#1: vaginal delivery c/b uterine inversion x 3. required\n laporatomy after 3rd uterine inversion. Continued drop in Hct (received 13\n units pRBCs). Need to evalaute for intra-abdominal bleed. please. \n with questions\n REASON FOR THIS EXAMINATION:\n evaluate for intr-abdominal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 29 year old woman post procedure day one status post vaginal\n delivery complicated by uterine inversion x 3 requiring laparotomy. Continued\n drop in hematocrit with 13 units of transfusion. Evaluate for intraabdominal\n bleed.\n\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis.\n\n FINDINGS: There are small pleural effusions bilaterally. There is a small\n amount of free intraperitoneal gas likely related to recent laparotomy. There\n is a small amount of free fluid distributed throughout the abdomen with low\n attenuation numbers. The liver, gallbladder, pancreas, spleen, adrenal glands\n and kidneys are unremarkable. The aorta is of normal caliber. There is no\n adenopathy. The unopacified bowel is unremarkable.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is a small amount of gas\n contained within the endometrial cavity. The uterus is enlarged. There is\n vaginal packing material present within the vaginal vault. The appearance of\n the adnexa is heterogeneous but symmetric, likely related to prominent\n parametrial veins, in addition to the adjacent ovary and tube. There is no\n evidence of retroperitoneal hematoma. The bones are unremarkable. There is\n an epidural catheter present on the left in the upper lumbar region whose tip\n does not appear to enter the spinal canal. There is a small amount of gas\n within the bladder, and there is a Foley catheter present within the bladder.\n\n There are surgical staples in the skin of the anterior abdominal wall.\n\n IMPRESSION: Small pleural effusions with small amount of ascites likely\n related to volume resuscitation and transfusions. No additional source for\n hematocrit drop identified.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-12-24 00:00:00.000", "description": "Report", "row_id": 1578413, "text": "Nursing Admit Note\n\nThis is a 29 yo female who delivered a baby , she was trasfered her s/p a uterin inversion after she delivered and a lg loss. Pt had a normal vaginal delivery, her baby was delivered early due to intrauterin growth restriction. After the baby was delivered there was a urerine inversion which was initially reduced. This happened 2 more times and required surgical intervention. She lost a lg amount of , SBP was charted at 69/ at one point and she had reported LOC. She was transfused at least 11 units of PRBC, 10 bags plts, 8 bags FFP. She was here for further care.\n\nAllergies: PCN\n\nSystems Review\n\nNeuro: A&Ox3, comfortable epidural in place, it was used enroute but capped when she got here. Anesthesia has seen her and plan to remove it tomorrow, it was left in place tonight in case it is needed for pain control. She has been given MS04 IV prn with good relief.\n\nCV: Her BP remains stable SBP 120-130, HR 60-80s SR. Her K, phos, and Ca have/are being repleted.\n\nGI: She remains NPO.\n\nGU: Brisk u/o, she has had > 2 liters out since arrival at 2 pm.\n\nOB/GYN: ABD with staples - dry and intact. ADB soft, slightly tender. She was given a unit of PRBC on arrival for a HCT of 27.9. She had a CT of her abd and pelvis which did not show active bleeding. Her packing was removed by OB, it was dark old , oxytosin gtt was started and will cont through the night. If she rebleeds then she would go to IR - they are aware of her and have already consented her. The lactation nurse came to see her and went over the breast pump with the pt and her husband. They will keep the milk in the 5 nursury.\n\nSoc: Her baby is still at in the NICU, she has only been able to see her briefly. We tried to have her baby here but were unable to do so. If she is well enough tomorrow than she may be able to be back to or if her baby is well enough to leave the NICU than she would be able to stay with the pt here.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-12-25 00:00:00.000", "description": "Report", "row_id": 1578414, "text": "7p-7a Nursing Note\nGeneral: Patient reports feeling \"much better\". Has been interacting with husband who slept in her room on a cot tonight. She was repleted with 1 gm calcium gluconate, received 15mmol of Kphosphate and is currently receiving 30mmol of Kphosphate. Her vaginal flow has been minimal requiring 1 pad change thus far in past 11 hours. Was medicated with prn morphine sulfate (2mg) IVP with good relief of incisional pain. Is on her second (of 2) liter of 10units oxytocin in 1000cc 0.9% NaCl. Patient has opted not to pump breast milk tonight but reports success of approximately 10cc at approximately 1800 last evening and reports that she is familiar with the breast pump and still desires to breast feed her baby girl.\n\nNeuro: Alert and oriented X3. MAE on command. Converses appropriately.\n\nCV: SR with rate 60's-70's and BP 120's/60's-130's/80's throughout the night. Her bilateral lower extremities are edematous up to mid calf.\n\nResp: Lung sounds are clear throughout. On 2lpm O2 via N/C SpO2 >95% throughout the night.\n\nGU/GI: Foley patent with clear yellow urine. Abdomen is soft and tender at surgical incision site. Her fundus is firm and 4cm below the umbilicus. Bowel sounds are active in all four quadrants.\n\nLines: to left AC and to right AC X2. Incidentally has been difficult to obtain tonight with patient requiring a total of 5 attempts by 4 separate nurses to obtain her third IV. She tolerated the IV attempts well and has does not report pain at any of the unsuccessful sites. Patient also has an epidural line that is capped and has not been used throughout the night.\n\nID: Staples in place to lower abdominal/upper pelvis region with no visible drainage. Wound is pink and appropriately warm to touch. T max 97.5, patient remains on IV clindamycin.\n\nSocial: As noted, patient's husband has been with patient throughout the night. Their newborn daughter remains in the NICU of an OSH. Patient and husband hope that daughter will be transferred here or patient will be allowed to return to OSH so that they will be able to visit daughter.\n\nPlan: Results of am labs are pending. Continue to support breast milk pumping. Watch for further vaginal bleeding. Full Code. Anesthesia note reports that they will remove epidural line sometime today.\n" } ]

[ { "category": "Echo", "chartdate": "2102-09-11 00:00:00.000", "description": "Report", "row_id": 104293, "text": "PATIENT/TEST INFORMATION:\nIndication: Source of embolism.\nStatus: Inpatient\nDate/Time: at 09:16\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nNormal abdominal aorta diameter. No thoracic aortic dissection.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. The TEE probe was passed with assistance from the\nanesthesioology staff using a laryngoscope. No TEE related complications. The\npatient appears to be in sinus rhythm.\n\nConclusions:\nPrebypass:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage.\n\nNo atrial septal defect is seen by 2D or color Doppler.\n\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%). Right ventricular chamber size and free wall\nmotion are normal.\n\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation.\n\nThe diameters of aorta at the sinus, ascending and arch levels are normal. No\nthoracic aortic dissection is seen. A mobile density is present in the aortic\narch approximately 5 cm proximal to the left carotid artery. The base of this\nmass measures 1.8 cm with a height into the aorta of 1.4 cm. Compared to TEE\non the mass has changed and there is no longer the approximately 1 cm\nball at the end of the stalk that is still present.\n\nPostbypass:\n\nMobile density in the ascending aorta is no longer present. Ascending aorta\nwalls are brightly echogenic consistant with a tube graft placement.\n\nBiventricular function is preserved. Estimated LV EF>55%.\n\nThe mitral regurgitation remains trace. Other valvular function remains\nunchanged.\n\n\n" }, { "category": "Echo", "chartdate": "2102-09-09 00:00:00.000", "description": "Report", "row_id": 104294, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic dissection.\nStatus: Inpatient\nDate/Time: at 02:57\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (mobile) atheroma in the ascending aorta. Normal descending\naorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was sedated for the TEE. Medications and dosages are listed above (see\nspray. Results were personally reviewed with the MD caring for the patient.\n\nConclusions:\nInitial Evaluation\n\nNo thrombus is seen in the left atrial appendage. Right ventricular chamber\nsize and free wall motion are normal. There is a complex (mobile) mass in the\nascending aorta that is large and freely mobile with a wide base narrow stalk\nand larger mass extending off the stalk.\nThe mass seems to wave to within 5 cm of the aortic valve, but seems to be\nattached in the arch.\nNo evidence of dissection.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation.\nThere is no pericardial effusion.\nDr. was notified in person of the results on at 0250.\n\n\n" }, { "category": "Echo", "chartdate": "2102-09-09 00:00:00.000", "description": "Report", "row_id": 104295, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic dissection. Chest pain.\nBP (mm Hg): 113/70\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 02:38\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Can't exclude aortic\ndissection.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - patient unable to cooperate. Emergency study performed by the\ncardiology fellow on call.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). An aortic\ndissection cannot be excluded. No aortic regurgitation is seen. The mitral\nvalve leaflets are structurally normal. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-09-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1251668, "text": " 9:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for emboli/ bleed\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with persistent headaches/ hx thrombosis, admitted with\n supratherapeutic INR\n REASON FOR THIS EXAMINATION:\n eval for emboli/ bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: HEAD CT WITHOUT CONTRAST.\n\n CLINICAL INDICATION: 39-year-old man with persistent headaches, history of\n thrombosis, admitted with supratherapeutic INR, evaluate for emboli - bleed.\n\n COMPARISON: No prior examinations of the head are available.\n\n TECHNIQUE: Axial MDCT images were obtained through the brain, no contrast was\n administered, the images were reviewed using soft tissue and bone window\n algorithms.\n\n FINDINGS: There is no evidence of acute or subacute intracranial hemorrhage,\n mass, mass effect, or shifting of the normally midline structures. The\n ventricles and sulci are normal in size and configuration for the patient's\n age. The soft tissues and bony structures are grossly unremarkable. The\n orbits are normal, the paranasal sinuses and the mastoid air cells are clear.\n\n IMPRESSION: There is no evidence of acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-09-09 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1251111, "text": " 1:21 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # \n Reason: need scan for operative planning\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 39M with aortic dissection, no images sent\n REASON FOR THIS EXAMINATION:\n need scan for operative planning\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 3:15 AM\n History: 39 yo M with Crohn's disease and is s/p ileal resection for ischemic\n bowel\n on , found to have thrombus in the SMA and SMV at that time. Severe\n back pain this AM and presented to the ED at Hospital. A CTA of the\n abdomen revealed an\n irregular dissection in the medial aspect of the ascending aorta.\n\n WET READ:\n 1. Irregular wispy structure in the midascending aorta with a broader base at\n the medial wall. Although the appearance is somewhat atypical, type A\n dissection is top in the differential diagnosis, especially considering the\n history of acute back pain. The irregularity of the dissection flap can be\n explained by cobweb appearance of the flap in the false lumen which represents\n ribbons of incompletely dissected media.\n However, given recent history of SMA thrombosis/embolus, a free floating\n intraluminal thrombus is in the differential diagnosis as well, but seems less\n likely. No extension into the aortic arch, supra-aortic vessels or coronary\n arteries. No hemopericardium, no hemothorax.\n 2. Occlusion of the distal SMA and particular the right sided branches.\n 3. Mild wall thickening and fat infiltration of the terminal ileum and cecum,\n likely due to chronic Crohn's disease, less likely ischemia.\n\n dw Dr. at 1:35, 2:00 and 2:45 am on in person and over the phone.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39 yo M with Crohn's disease and is s/p ileal resection for\n ischemic bowel on , found to have thrombus in the SMA and SMV at that\n time. Severe back pain this AM and presented to the ED at Hospital. A\n CTA of the abdomen revealed an irregular dissection in the medial aspect of\n the ascending aorta.\n\n TECHNIQUE: Contiguous MDCT images through the chest, abdomen, and pelvis were\n obtained after the administration of intravenous contrast. Delayed phase\n imaging was obtained prior to the CTA. Axial, coronal, and sagittal reformats\n of the torso were obtained.\n\n COMPARISON: None.\n\n FINDINGS:\n\n CTA OF THE CHEST:\n (Over)\n\n 1:21 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # \n Reason: need scan for operative planning\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is a focal type A dissection of the mid ascending aorta with a small\n intramural hematoma and associated intraluminal thrombosis abutting the\n dissection flap. No extension of the dissection into the aortic arch,\n supra-aortic vessels or coronary arteries. No hemopericardium, and no\n hemothorax. The aortic arch and descending thoracic aorta are normal. The\n pulmonary artery is normal. There is no focal lung consolidation and no\n pneumothorax or suspicious pulmonary nodules. The central airways are patent.\n\n CTA OF THE ABDOMEN:\n Focal fatty infiltration of the liver is seen at the falciform ligament.\n There are no focal hepatic lesions. The gallbladder shows a combination of\n stones and vicarious secretion (from OSH CT). The pancreas, spleen, both\n adrenal glands, and kidneys are normal. The portal venous system of the\n abdomen and pelvis is normal. The abdominal aorta, celiac axis, , and\n renal arteries are patent. The distal SMA is occluded (series 2, image 152)\n particular the right sided branches. There is no retroperitoneal or mesenteric\n lymphadenopathy. The stomach and large bowel are normal. There is a small\n bowel anastomosis site in the mid lower abdomen and pelvis with fat\n infiltration of the wall in the terminal ileum and cecum, likely due to\n chronic Crohn's disease. There is no evidence of bowel obstruction.\n\n CTA OF PELVIS:\n The urinary bladder, seminal vesicles, and prostate gland are normal. A\n midline laparotomy incision is seen. There is atherosclerotic plaque and\n calcification of the left external iliac artery and CFA.\n\n BONES: No suspicious lytic or sclerotic bony lesions. Sacroiliac joint\n sclerotic changes are demonstrated.\n\n IMPRESSION:\n 1. Focal type A dissection of the mid ascending aorta with a small intramural\n hematoma and associated intraluminal thrombus abutting the dissection flap.\n No extension of the dissection into the aortic arch, supra-aortic vessels or\n coronary arteries. No hemopericardium, and no hemothorax.\n 2. Occlusion of the distal SMA and particular the right sided branches.\n 3. Fat infiltration of the terminal ileum wall and cecum explained by chronic\n Crohn's disease.\n\n dw Dr. at 1:35, 2:00 and 2:45 am on in person and over the phone.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251419, "text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p Asc ao replacement and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old male status post ascending aorta replacement and\n chest tube removal.\n\n COMPARISON: Comparison is made with chest radiograph from .\n\n FINDINGS: Two frontal images of the chest demonstrate low lung volumes,\n likely related to poor inspiration. There has been interval removal of the\n Swan-Ganz catheter. Right IJ sheath is in place. There has been interval\n extubation. The NG tube has been removed. There is no pneumothorax or other\n complications seen. The chest exam is otherwise essentially unchanged from\n previous imaging. There is no evidence of acute pulmonary or cardiac\n pathology. There are no pleural effusions. The cardiomediastinal silhouette\n is unchanged.\n\n IMPRESSION: Multiple support and maintenance devices removed with no\n complication seen. Otherwise essentially unchanged exam with no evidence of\n acute pulmonary or cardiac process\n\n" }, { "category": "Radiology", "chartdate": "2102-09-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1251323, "text": " 12:04 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with s/p Removal of Aortic Mass\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old male status post removal of aortic mass.\n\n COMPARISON: None.\n\n FINDINGS: Four frontal images of the chest demonstrate a Swan-Ganz catheter\n with the tip in the pulmonary arteries. ET tube is in position 4.6 cm above\n the carina. NG tube passes along the expected course into the stomach and out\n of view. There is no pneumothorax or other complication seen. There is\n bilateral atelectasis and additional atelectasis in the right middle lobe.\n There are no pleural effusions. The lungs are generally clear. The\n cardiomediastinal silhouette is unremarkable.\n\n IMPRESSION: Expected post-operative appearance with no evidence of acute\n pulmonary or cardiac pathology.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1251592, "text": " 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fevers, evaluate for pna\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with s/p excision of aortic mass, Ascending aorta replacement\n REASON FOR THIS EXAMINATION:\n fevers, evaluate for pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative fever, to assess for pneumonia.\n\n FINDINGS: In comparison with the study of , the right IJ sheath has been\n removed. The cardiac silhouette remains within normal limits. Continued poor\n definition of engorged pulmonary vessels consistent with elevated pulmonary\n venous pressure. In the appropriate clinical setting, supervening pneumonia\n would be difficult to exclude.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-09-16 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1251946, "text": " 12:43 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: evaluate for abscess\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man POD5 Asc Ao persistent fevers abscess right antecubical\n REASON FOR THIS EXAMINATION:\n evaluate for abscess\n ______________________________________________________________________________\n WET READ: SAT 1:37 PM\n Focal thrombus in the right basilic vein at the antecubital fossa. Mid-to-\n upper portion of right basilic vein is patent. No evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-op day 5 with persistent fevers. Assess for right\n antecubital fossa abscess.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color son were acquired of the right internal\n jugular, subclavian, axillary, brachial, basilic, and cephalic veins. There\n is a focal thrombus within the lower portion of the basilic vein at the level\n of the antecubital fossa, at the site of prior intravenous access. The mid to\n upper portion of the right basilic vein is patent. There is normal\n compression and flow throughout the remainder of the visualized venous\n structures. A linear echogenic focus in the right internal jugular vein could\n represent a valve, fibrin deposit, or old residual thrombus. No subcutaneous\n fluid collection is identified.\n\n IMPRESSION:\n\n 1. Focal thrombus within the right basilic vein at the level of the\n antecubital fossa. No evidence of DVT in the right upper extremity.\n\n 2. Echogenic focus in the right internal jugular vein, possibly represent a\n valve, fibrin deposit, or old retracted clot. However, no evidence of acute\n DVT.\n\n 2. No subcutaneous fluid collection concerning for abscess.\n\n" }, { "category": "ECG", "chartdate": "2102-09-11 00:00:00.000", "description": "Report", "row_id": 305426, "text": "Sinus tachycardia. Normal tracing, except for rate. Compared to the previous\ntracing of the heart rate is faster and there is T wave flattening in\nthe mid-precordial leads consistent with myocardial ischemia. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2102-09-09 00:00:00.000", "description": "Report", "row_id": 305427, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2168-12-21 00:00:00.000", "description": "Report", "row_id": 1320120, "text": "NURSING ACCEPTANCE NOTE:\n\nPt is an 88YO male transferred to MICU A from 7 s/p PEA arrest.\n\nHPI: Pt was initially admitted with c/o dizziness, and was found to have large LLE DVT for which he was being treated w/Heparin. Early this AM pt was assisted OOB to bathroom. He was having BM when he c/o dizziness then became unresponsive with undetectable pulse. Found to be in PEA for which he recieved CPR, IVF, several rounds of Atropine and Epi with return of pulse but essentially no BP. He was then started on w/o Dopa, with Levo and Vasopressin added. He was also given 100mg TPA given high suspicion of PE (arrest was witnessed and there was no evidence of head trauma).\n\nALL: NKDA\n\nROS:\nNEURO: Pt arrived with fixed, dilated pupils, which are now decreasing in size somewhat (presumed lingering effect of atropine). Weak gag, cough and corneals; does not f/c. No spontaneous movement of LE's slight decorticate posturing of UE's.\nRESP: Pt intubated on vent settings of CMV .5/600/22/5, taking 4-8 breaths over set rate with TV's as high as 2L. ABG's show significant metabolic acidosis but are improving. Vent being adjusted prn. LS coarse t/o; suctioned for small amt frothy white sputum. ETT placement confirmed by CXR.\nC-V: Initially in 3rd-degree HB with rate in low-100's; has converted to ST with rare PVC's. EKG done. Pt arrived with BP in 120's, soon rising to 150's. Dopa and Vasopressin quickly weaned off and Levo titrated down to .25, but has required increase since. Goal is MAP in 80's. Weak DP and PT pulses; L leg considerably larger than right. Scattered mottling over LE's. Lytes, cardiac enzymes pending.\nHEME: Pt to be restarted on Heparin gtt pending PTT result (sent after arrival). Pt has hematoma at R femoral TLC site; pressure held for several minutes after arrival with improvement, but he is still oozing from that site. No other evidence of bleeding. CBC and coags are pending.\nGI: Belly benign; hypoactive BS, no stool. OGT placed and connected to LCWS with output of small amount pink-tinged fluid. OGT placement was confirmed by auscultation but not radiologically.\nGU: Foley placed on arrivial; initially no UO, but since has had a few drops of urine with lots of sediment. BUN/creat pending.\nID: Pt hypothermic with cooling blanket in use. WBC pending. ? of pnx on admission, no other ID issues apparent.\nENDO: No report of issues; awaiting serum glucose.\nSKIN: Intact; mottling as described above.\nACCESS: R arm PIV. R femoral TLC placed during code which was noted to be partially dislodged on arrival to floor with hematoma as described above. Line advanced and resutured by attending; all ports have good blood return and flush easily. L femoral a-line placed.\nSOCIAL: Family has been contact and are on their way in. Reportedly code status was to have been addressed today.\n\nA/P: 88YO male s/p PEA arrest possibly d/t PE; unclear neurological status, though code was prolonged. Family is on their way; further course of treatment to be \n" }, { "category": "Nursing/other", "chartdate": "2168-12-21 00:00:00.000", "description": "Report", "row_id": 1320121, "text": "(Continued)\nided pending meeting w/family.\n" }, { "category": "Nursing/other", "chartdate": "2168-12-21 00:00:00.000", "description": "Report", "row_id": 1320122, "text": "Nursing Progress Note 0700-1900\n Pt continues to show neurologic decline from anoxic brain injury, s/p 40-45 minutes of CPR. CT head showing no bleed. Vasopressors weaned up and down. New onset GIB (s/p TPA), hct drop from 31 to 26 this am. Several family meetings today, daughter repeatedly stating that pt would not want this. Decided to withdraw care tomorrow am after all family has been contact and given a chance to be present. code status changed: DNR/DNI\n\nROS/PE:\n\nCV- NSR, HR 90-110's, no ectopy. ABP 90-120's on 0.25mcg/kg/min levophed. vasopressin weaned off. LLE edematous from DVT. last hct 25. most recent ptt 57, INR 2.4.\n\nRESP- vent settings AC 22x600/5/40 w/ last abg of 7.39/26/130/-. Pt is overbreathing vent by , taking almost 1L volumes. breathing becoming more agonal. LS coarse.\n\nNEURO- interittent myoclonic jerking. EEG showing some sz spikes, but no prolonged SZ activity. pupils 3mm and sluggish. + nystagmus, - dolls eyes. Decorticate postering present in UE's w/ stimulation. no movement or withdrawl of pain on LE's. does not open his eyes or interact at all. Has recieved no sedation medications.\n\nGI/GU- OGT clamped. abd soft/ ND. having large amt bloody diarrhea into mushroom catheter. briefly on insulin gtt this am, now has been intermittently hypoglycemic throughout the day, requiring D50 x2. anuric despite 1000cc NS bolus x2.\n\nSKIN- bruising to chest, ?from CPR. oozing from femoral central line site. surgifoam applied.\n\nACCESS- R fem TLC, L fem Aline. Piv x1.\n\nSOCIAL- daughter in to visit with her 3 daughters most of the day. very involved and supportive. tearful, asking appropriate questions. Offered support. SW consulted. Daughter to contact her sister and son and will plan on having family here tomorrow am.\n\nPLAN- will start MSO4 gtt to ensure pt's comfort, titrate up as needed for breathing/ comfort. all meds dc'ed except levophed. Plan is not to escalate care, may go up on levophed, but not to add another other . Essentially CMO, but continuing supportive measures until am. DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2168-12-21 00:00:00.000", "description": "Report", "row_id": 1320123, "text": "Resp Care\nPt remains on AC, pt went for a head ct. Plan to withdraw support .\n" }, { "category": "Nursing/other", "chartdate": "2168-12-22 00:00:00.000", "description": "Report", "row_id": 1320124, "text": "REsP CARE; Pt remains intubated/on full vent support per carevue. No changes this shift.\n" }, { "category": "Nursing/other", "chartdate": "2168-12-22 00:00:00.000", "description": "Report", "row_id": 1320125, "text": "pmicu 7p-7a\n\n\n there was no change in the pt's condition overnoc. he has had a 20 point decline in his heart rate while his blood pressure continues to be marginal on the maximum dosage of levophed. he has had essentially no uop .\n\nreview of systems\n\nrespiratory-> the pt continues to be intubated and vented on ac 22x600 w/peep5 and fio2 40%. srr 0-3/min. suctioned x2 for small amts of white sputum.\n\ncardiac-> hr 70-80's, sr w/rare pvc's. sbp ranging 75-95. plan to continue w/the levophed qtt for now but w/no escalation of treatment.\n\nneuro-> perrl @3mm with a sluggish response. no purposeful or spontaneous movement noted. +flexion of extremities to noxious stimulation. no posturing\n\ngi-> abd is soft, nontender w/+bs. ogt residuals were consistently >60. pt continues to pass liquid, ob+ diarrhea via a mushroom catheter.\n\ngu-> essentially no uop via foley. + peripheral edema more notable .\n\naccess-> right femerol tlcl, left femerol a-line are both patent and intact. both lines were redressed w/gelfoam due to bleeding at the insertion sites.\n\nsocial-> family meeting with the pt's dtr and grandchildren planned for later today to readdress withdrawal of aggressive care measures. pt is a dnr.\n" }, { "category": "Nursing/other", "chartdate": "2168-12-22 00:00:00.000", "description": "Report", "row_id": 1320126, "text": "NPN 7a-7p:\n S/O: please see transfer note for details of admission and plan. Briefly, decision was made by pt's family to extubate, d/c vasopressors and make pt . Pt was on MSO4 gtt at 2mg/hr, which continues, after 2mg iv bolus given prior to extubation. vasopressors dc'd at 11:30am, and pt extubated at that time. His SBP has been 80's-90's since that time, sats mid 80's-mid 90's,, HR 80's-90's. afebrile. family at bedside. Chaplain was in and offered prayers/blessing with pt/family. Pt's daughter, 4 grandchildren at bedside and updated throughout day. Pt has remained without signs/symptoms pain or air hunger, and has not required further pain meds. A/P: pt has been called out to floor to continue comfort measures. Family aware. no bed at this time.\n" }, { "category": "Radiology", "chartdate": "2168-12-19 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 888291, "text": " 2:20 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please eval for ruptured cyst and dvt.\n Admitting Diagnosis: DIZZINESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with metastatic prostate cancer; admittedwith lightheadedness.\n Now with acute onset of LLE pain/swelling.\n REASON FOR THIS EXAMINATION:\n Please eval for ruptured cyst and dvt.\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX ULTRASOUND OF VEINS\n\n INDICATION: Swelling in leg. Patient with history of prostate cancer.\n\n TECHNIQUE: Grayscale, color flow and pulse-wave Doppler insonation of the\n deep veins of the left leg was performed.\n\n COMPARISON: No examination available for comparison.\n\n REPORT:\n There is extensive acute intraluminal occlusive thrombus involving the deep\n veins of the left side extending from the below-knee tibial veins to the level\n of and involving the common femoral vein. Within the posterior aspect of the\n knee there is also identified a 3.6 x 2.5 cystic structure which contains\n intraluminal echogenic material, which has the morphology of cyst.\n This is non-vascular and is not thought to represent a vascular lesion.The\n intracystic echogenic material probably represents fibrinous debris and/or\n clot. The deep veins of the right groin appear compressible with normal\n augmentation and respiratory variation. A small amount of circumferential\n thickening on the right side may represent recanalization from the previous\n DVT.\n\n The remainder of the right leg is not examined.\n\n CONCLUSION:\n 1. Extensive deep venous thrombosis on left side.\n 2. Complicated cyst, left popliteal fossa.\n 3. Possible chronic nonocclusive recanalized thrombosis of right SFV. The\n results were telephoned to referring doctor at 5 p.m. on .\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2168-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888487, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: DIZZINESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with cardiac arrest\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Endotracheal tube placement. Cardiac arrest.\n\n An endotracheal tube is in place, terminating approximately 6 cm above the\n carina, located at the thoracic inlet level. Cardiac and mediastinal contours\n are stable. There has been interval worsening of the bilateral interstitial\n pattern with associated perihilar haziness and numerous septal lines. As\n noted previously, the heart size is within normal limits.\n\n IMPRESSION:\n 1. Satisfactory placement of endotracheal tube.\n 2. Slight worsening of bilateral symmetrical interstitial pattern with normal\n heart size. This may reflect interstitial pulmonary edema. However, in the\n setting of a normal heart size, additional diagnostic considerations include\n atypical pneumonia, and more chronic interstitial processes including\n lymphangitic spread of tumor and interstitial fibrosis. If this fails to\n respond clinically and radiographically to diuresis, high-resolution CT may be\n considered.\n\n" }, { "category": "ECG", "chartdate": "2168-12-21 00:00:00.000", "description": "Report", "row_id": 204238, "text": "Baseline artifact\nSinus rhythm\nRight ventricular conduction delay pattern\nModest nonspecific low amplitude inferolateral T waves, although baseline\nartifact makes assessment difficult\nSince previous tracing of , Modest right ventricular conduction delay\npattern and low amplitude T waves suggestsed but baseline artifact makes\ncomparison difficult\n\n" }, { "category": "ECG", "chartdate": "2168-12-20 00:00:00.000", "description": "Report", "row_id": 204239, "text": "Baseline artifact\nSinus rhythm with ventricular premature complexes\nOtherwise normal ECG\nSince previous tracing of , ventricular ectopy present\n\n" }, { "category": "ECG", "chartdate": "2168-12-18 00:00:00.000", "description": "Report", "row_id": 204240, "text": "Normal sinus rhythm, rate 93. No diagnostic abnormality. No previous tracing\navailable for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2168-12-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 888170, "text": " 2:00 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with dizziness.\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old male with dizziness. Evaluate for pneumonia.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: PA and lateral views of the chest.\n\n FINDINGS: The heart is of normal size. The pulmonary vascularity appears to\n be within normal limits. However, there are Kerley B lines and increased\n interstitial opacities bilaterally. Although these findings could be due to\n interstitial pulmonary edema, other causes of interstitial disease should also\n be considered. There are no focal consolidations or pleural effusions. The\n skeletal structures are grossly unremarkable. There are surgical clips in the\n gallbladder fossa.\n\n IMPRESSION:\n 1. No evidence of consolidation.\n 2. Bilateral symmetric increased interstitial opacities with bilateral septal\n lines. Statistically this is most likely due to interstitial pulmonary edema.\n Nevertheless the heart is of normal size and there are no pleural effusions.\n If this findings persist after diuresis, other causes of interstitial lung\n disease should be considered and high resolution CT of the chest should be\n performed.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2168-12-19 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 888307, "text": " 3:54 PM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: Evaluate for acute fracture\n Admitting Diagnosis: DIZZINESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with acute onset pain, swelling LLE.\n REASON FOR THIS EXAMINATION:\n Evaluate for acute fracture\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Left knee.\n\n HISTORY: Acute onset pain, swelling, left lower extremity.\n\n Left knee: Three views show moderate loss of cartilage in the medial\n compartment of the left knee. There is small joint effusion. Note is also\n made of varus deformity. There is probable loose body in the joint. There is\n no evidence of fracture.\n\n IMPRESSION: Advanced medial osteoarthritis of the left knee and small joint\n effusion.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2168-12-20 00:00:00.000", "description": "RENAL U.S.", "row_id": 888426, "text": " 1:56 PM\n RENAL U.S. Clip # \n Reason: please eval for obstructive disease/hydronephrosis.\n Admitting Diagnosis: DIZZINESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with acute renal failure in setting of metastatic prostate\n cancer.\n REASON FOR THIS EXAMINATION:\n please eval for obstructive disease/hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of acute renal failure and metastatic prostate cancer.\n Evaluate for obstructive disease or hydronephrosis.\n\n COMPARISON: None.\n\n RENAL ULTRASOUND: The right kidney measures 10.3 cm. The left kidney\n measures 10.3 cm. There is no hydronephrosis or stones. The bladder is\n normal in appearance, without any evidences of wall thickening. The prostate\n appears enlarged.\n\n IMPRESSION: No hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2168-12-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 888549, "text": " 12:27 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: concern for ICH\n Admitting Diagnosis: DIZZINESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with PEA arrest, PE, metastatic prostate CA on heparin\n REASON FOR THIS EXAMINATION:\n concern for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE HEAD WITHOUT CONTRAST\n\n HISTORY: 88-year-old male with metastatic prostate cancer, on heparin.\n Evaluate for intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is extensive motion artifact on all imaged levels. There is\n no evidence of a large intracranial hemorrhage and no midline shift. There is\n hypodensity high in the right posterior frontal parietal region. This could\n represent a subacute to chronic infarct or an edema producing cortical lesion\n such a metastatic focus.\n\n IMPRESSION: No evidence of an acute intracranial hemorrhage. Hypodense\n region in the right frontoparietal area, which could represent a cortical\n metastatic lesion or a subacute to chronic infarct.\n\n" } ]

[ { "category": "Echo", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 77977, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic stenosis and Aortic insufficiency\nHeight: (in) 67\nWeight (lb): 125\nBSA (m2): 1.66 m2\nBP (mm Hg): 100/60\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:36\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severely\ndepressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\nNormal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS (AoVA\n1.0-1.2cm2) Moderate to severe (3+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage.\nNo atrial septal defect is seen by 2D or color Doppler.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is moderately dilated. Overall left ventricular systolic function is\nseverely depressed (LVEF= 20 %).\nRight ventricular chamber size and free wall motion are normal.\nThere are complex (>4mm) atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta.\nThe aortic valve leaflets are moderately thickened. There is moderate aortic\nvalve stenosis (area 1.0-1.2cm2). Moderate to severe (3+) aortic regurgitation\nis seen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no pericardial effusion.\nDr. was notified in person of the results on before\nsurgery start.\n\nPost_Bypass:\nPatient is on an infusion of epinephrine 0.02mcg/kg/min and vasopressin 3\nunits/hour.\nMild RV global hypokinesis.\nOverall LVEF 15% to 20%.\nIntact thoracic aorta.\nA bioprosthesis is seen in the native aortic valve position, stable and\nfunctioning well with mean gradients of 8mm of Hg and no residual aortic\nregurgitation.\nMild MR and Mild TR.\n\n\n" }, { "category": "Echo", "chartdate": "2162-01-19 00:00:00.000", "description": "Report", "row_id": 77978, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function.\nBP (mm Hg): 116/71\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 09:21\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Normal regional\nLV systolic function. Low normal LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Moderately dilated aortic sinus. Normal aortic arch diameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (AoVA <0.8cm2). Mild to moderate (+) AR.\nEccentric AR jet directed toward the anterior mitral leaflet. [Due to acoustic\nshadowing, AR may be significantly UNDERestimated.]\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Moderate\nmitral annular calcification. Moderate thickening of mitral valve chordae.\nCalcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Frequent\nventricular premature beats.\n\nConclusions:\nThe left atrium is moderately dilated. The left atrium is elongated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity is\nmildly dilated. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is low normal (LVEF 50 %). Right ventricular\nchamber size and free wall motion are normal. The aortic root is moderately\ndilated at the sinus level. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are severely thickened/deformed. There\nis severe aortic valve stenosis (area <0.8cm2). Mild to moderate (+) aortic\nregurgitation is seen. The aortic regurgitation jet is eccentric, directed\ntoward the anterior mitral leaflet. [Due to acoustic shadowing, the severity\nof aortic regurgitation may be significantly UNDERestimated.] The mitral valve\nleaflets are severely thickened/deformed. There is moderate thickening of the\nmitral valve chordae. Mild (1+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\nIMPRESSION: Severe aortic stenosis. Mild to moderate aortic regurgitation.\nLow-normal left ventricular systolic function. Moderate pulmonary\nhypertension. Moderate aortic root dilation.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function is mildly reduced, the left ventricular cavity size is\nlarger and the severity of aortic stenosis has progressed.\n\n\n" }, { "category": "Nursing", "chartdate": "2162-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554183, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Arrived from OR on high dose levo, vaso, epi and prop. 2 mediastinal\n chest tubes, 2 functional a and v wires. PA pressures wnl, cvp\n consistently low, nonresponsive to fluid boluses?d/t sedation.\n Reversed without incident. Abg acidotic, corrected with vent changes.\n Progressing well. Difficult to sedate opens eyes to voice and follows\n commands on 50-60 mcg propofol. Denies pain shaking head. Treated\n with morphine for presumed pain evidenced by tachycardia and\n hypertension on turning in bed. CI 2.5-3 svo2 60\ns. radial and fem\n a lines. Following fem line pressures.\n Action:\n Monitored, Weaned epi, levo and pit. Reversed anesthesia and woke for\n neuro check. Pain treated with morphine IV. Vent changes to correct\n acidocis. ETT re-secured with duoderm ETT holder. Insulin gtt added\n Response:\n Pt beginning to stabilize, tolerating wean of gtts. This AM becoming\n more agitated, sedation increased with good effect. Blood glucose\n stable on 1 unit insulin.\n Plan:\n Continue to monitor, continue to wean gtts, ?wake and wean to extubate\n this AM, if so transition to RISS and lantus SC.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Creatinine this AM. Had HD pre-op. L arm AVfistula\n +thrill+bruit. Pt making 10-20 cc/hour of very light yellow clear\n urine. Apparently poor nutritional status ? need for tubefeeds even if\n extubates today. Does not appear edematous. Rec\nd 2L crys in OR and\n 2L post.\n Action:\n Monitored.\n Response:\n Pending\n Pan:\n ?need HD this weekend as creat , monitor labs. ? need for\n tubefeeds for supplement to oral intake post extubation.\n" }, { "category": "Nursing", "chartdate": "2162-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554289, "text": "HD8\n POD #1\n 60 yo M s/p AVR (#27mm tissue valve )-\n PMH: ESRD on HD (MWF), bicuspid AV w/AS, AI, HTN, hip C(s/p Pegasysx\n 48wks), HTN, ^ chol, Hyperhomocysteinemia, Secondary\n hyperparathyroidism, Lumbago-methadone, Anemia.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Lightly sedated on propofol able to nod head yes/no to\n questions. MAE x\ns 4 to command. Stable hemodynamics on levo and Epi.\n Epicardial wires. 2 Mediastinal chest tube. Right fem and radial A\n lines. RIJ cordis w/CCO swan. Generalized puffy edema. NSR -> ST\n w/freq PACs.\n Intubated on Vent. Breath sounds clear.\n Abd soft w/act BS, OG tube to sx\n Foley cath patent\n Insulin gtt for glucose mngt\n IC 1.10\n Action:\n Propofol weaned off. Percocet for pain mngt\n Epi and Levo weaned off, CCO dc\nd. CT to 20cm sx. Fem A line\n dc\nd. Amiodarone po started. Metoprolol 12.5 mg po started after 1 time\n dose of IV 5 mg. Wires checked\n Extubated to NC 3 L/min. Pulmonary toilet.\n OG tube dc\nd. Taking sips and chips and PO meds\n Insulin gtt weaned off\n Ca+ gluc 2 gm\n Response:\n A+O x\ns 3. MAE x\ns 4, noodle like legs when getting OOB.\n Good effect from percocet.\n Hemodynamics remain stable. NSR w/freq PACs. Both A and V\n wires sense and capture appropriately.\n Sats 95% or >. No resp distress noted, = rise and fall of\n chest. Pulls ~ 800 ml w/ IS. CT dumps 100 cc after getting OOB\n Tolerating meds and sips/chips w/o difficulties.\n FSG <120\n Plan:\n Pulmonary toilet. Mobilize, monitor, tx, support, and\n comfort. Txfr to 6 tomorrow.\n" }, { "category": "Nursing", "chartdate": "2162-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554283, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Lightly sedated on propofol able to nod head yes/no to questions. MAE\n x\ns 4 to command. Stable hemodynamics on levo and epi. Epicardial\n wires. 2 Mediastinal chest tube. Right fem and radial A lines. RIJ\n cordis w/CCO swan. Generalized puffy edema. NSR -> ST w/freq PACs.\n Intubated on Vent. Breath sounds clear.\n Abd soft w/act BS, OG tube to sx\n Foley cath patent\n Insulin gtt for glucose mngt\n IC 1.10\n Action:\n Propofol weaned off\n Epi and levo weaned off, CCO dc\nd. CT to 20cm sx. Fem A line dc\n Amiodarone po started. Metoprolol 12.5 mg po started after 1 time dose\n of IV 5 mg.\n Extubated\n OG tube dc\n Insulin gtt weaned off\n Ca+ gluc 2 gm\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554287, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Lightly sedated on propofol able to nod head yes/no to\n questions. MAE x\ns 4 to command. Stable hemodynamics on levo and epi.\n Epicardial wires. 2 Mediastinal chest tube. Right fem and radial A\n lines. RIJ cordis w/CCO swan. Generalized puffy edema. NSR -> ST\n w/freq PACs.\n Intubated on Vent. Breath sounds clear.\n Abd soft w/act BS, OG tube to sx\n Foley cath patent\n Insulin gtt for glucose mngt\n IC 1.10\n Action:\n Propofol weaned off. Percocet for pain mngt\n Epi and levo weaned off, CCO dc\nd. CT to 20cm sx. Fem A line\n dc\nd. Amiodarone po started. Metoprolol 12.5 mg po started after 1 time\n dose of IV 5 mg. Wires checked\n Extubated to NC 3 L/min. Pulmonary toilet.\n OG tube dc\nd. Taking sips and chips and PO meds\n Insulin gtt weaned off\n Ca+ gluc 2 gm\n Response:\n A+O x\ns 3. MAE x\ns 4, noodle like legs when getting OOB.\n Good effect from percocet.\n Hemodynamics remain stable. NSR w/freq PACs. Both A and V\n wires sense and capture appropriately.\n Sats 95% or >. No resp distress noted, = rise and fall of\n chest. Pulls ~ 800 ml w/ IS. CT dumps 100 cc after getting OOB\n Tolerating meds and sips/chips w/o difficulties.\n FSG <120\n Plan:\n Pulmonary toilet. Mobilize, monitor, tx, support, and\n comfort. Txfr to 6 tomorrow.\n" }, { "category": "Physician ", "chartdate": "2162-01-23 00:00:00.000", "description": "ICU Note - CVI", "row_id": 554274, "text": "CVICU\n HPI:\n HD8\n POD #1\n 60 yoM s/p AVR (#27mm tissue valve )-\n EF 15% CR WT HgA1c\n PMH: ESRD on HD (MWF), bicuspid AV w/AS, AI, HTN, hep C(s/p Pegasysx\n 48wks), HTN, ^chol, Hyperhomocysteinemia, Secondary\n hyperparathyroidism, Lumbago-methadone, Anemia.\n CURRENT MEDS: Epo @ HD, ASA 81', Sensipar 120', Docusate 100\", Flomax\n .8', Lisinopril 20\", Methadone 10''', Protonix 40\",Renagel 800''',\n Dialyvite 800, Lipitor 80'\n 24hr events\n Current medications:\n Acetaminophen Amiodarone . Aspirin . Atorvastatin . Calcium\n Gluconate. Docusate Sodium Insulin. Magnesium Sulfate . Metoclopramide\n . Metoprolol Tartrate . Milk of Magnesia . Morphine Sulfate .\n Nitroglycerin . Oxycodone-Acetaminophen Pantoprazole . Tamsulosin .\n Vancomycin\n 24 Hour Events:\n INTUBATION - At 05:48 PMIn OR\n OR RECEIVED - At 05:48 PM\n INVASIVE VENTILATION - START 05:48 PM\n INTUBATION - At 05:57 PM\n was intubated in the OR time not known but transferred post\n procedure to CVICU-A sedated and intubated.\n ARTERIAL LINE - START 05:59 PM\n CORDIS/INTRODUCER - START 06:00 PM\n CCO PAC - START 06:01 PM\n ARTERIAL LINE - START 06:04 PM\n EKG - At 07:25 PM\n Post operative day:\n POD#1 - S/P AVR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 11:27 PM\n Morphine Sulfate - 05:00 AM\n Ranitidine (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 10:00 AM\n Other medications:\n Flowsheet Data as of 03:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 93 (79 - 103) bpm\n BP: 114/64(77) {114/63(77) - 131/85(97)} mmHg\n RR: 16 (12 - 25) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 16 (6 - 20) mmHg\n PAP: (51 mmHg) / (26 mmHg)\n CO/CI (Fick): (5.2 L/min) / (3.1 L/min/m2)\n CO/CI (CCO): (6.4 L/min) / (4.3 L/min/m2)\n SvO2: 67%\n Mixed Venous O2% sat: 82 - 82\n Total In:\n 4,753 mL\n 3,033 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,503 mL\n 2,923 mL\n Blood products:\n 1,250 mL\n Total out:\n 208 mL\n 438 mL\n Urine:\n 78 mL\n 128 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 4,545 mL\n 2,595 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 551 (501 - 551) mL\n Vt (Spontaneous): 501 (501 - 501) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 11 cmH2O\n Plateau: 14 cmH2O\n Compliance: 61.2 cmH2O/mL\n SPO2: 99%\n ABG: 7.40/37/124/27/0\n Ve: 11.6 L/min\n PaO2 / FiO2: 248\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular), freq. APCs, occ VPC\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 121 K/uL\n 9.9 g/dL\n 81 mg/dL\n 4.1 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 105 mEq/L\n 139 mEq/L\n 27.7 %\n 8.1 K/uL\n [image002.jpg]\n 03:42 PM\n 04:08 PM\n 04:45 PM\n 06:07 PM\n 06:17 PM\n 08:14 PM\n 11:11 PM\n 02:50 AM\n 03:30 AM\n 10:08 AM\n WBC\n 13.3\n 10.1\n 8.1\n Hct\n 21\n 21\n 22.7\n 29.3\n 25.6\n 27.7\n Plt\n 134\n 119\n 121\n Creatinine\n 3.8\n 4.1\n TCO2\n 32\n 30\n 28\n 28\n 24\n Glucose\n 129\n 96\n 89\n 75\n 84\n 85\n 85\n 81\n Other labs: PT / PTT / INR:16.5/36.4/1.5, Differential-Neuts:79.6 %,\n Lymph:14.8 %, Mono:2.8 %, Eos:2.4 %, Fibrinogen:282 mg/dL, Lactic\n Acid:2.4 mmol/L\n Assessment and Plan\n VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD)\n Assessment and Plan: Stable. Extubated this AM. Weaned from all\n pressors, now htnive. Plan HD \n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, HD, HD \n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Fluids: KVO\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Arterial Line - 05:59 PM\n Cordis/Introducer - 06:00 PM\n 16 Gauge - 06:02 PM\n 20 Gauge - 06:03 PM\n Prophylaxis:\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2162-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554485, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n A+O x\ns 3. MAE x\ns 4. Pain controlled well\n NSR w/o ectopy w/intermittent A pacing @ rate 60. VSS. Metoprolol 25\n po BID, Lisinopril started last evening. 2 CT draining serosang minimal\n amt. Has 2 A and 2 V Epicardial wires. Drsg .\n Breath sounds clear, O2 3L/min per NC. Productive cough dark tan yellow\n Abd soft w/active BS.\n FSG > 120\n Action:\n Percocet PRN for pain mngt.\n Pulmonary toilet, O2 weaned to 2 L. CT dc\n OOB to chair\n Diet advanced\n RSSI sq per protocol\n Response:\n Good effect from Percocet\n Sats 93% or >. No resp distress noted, = rise and fall of chest.\n Transfers w/standby assist\n Tolerates diet\n FSG > 175\n Plan:\n Pulmonary toilet, mobilize, monitor, tx, support, and comfort. Dc to\n home by mid week.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Minimal HUO via foley\n BUN 29/Creatinine 5.9\n K 6.1, Phos 6.3\n Action:\n K rechecked\n Phos binding drugs ordered and initiated\n Response:\n K on recheck = 5.9\n Plan:\n HD today 2 hr run\n" }, { "category": "Nursing", "chartdate": "2162-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554489, "text": "Demographics\n Attending MD:\n C.\n Admit diagnosis:\n S/P VTACH\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 57.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, COPD, ETOH, GI Bleed, Hepatitis, Renal Failure\n CV-PMH: CAD, CHF, Hypertension, MI\n Additional history: ESRD-HD(MWF) @ with L AV fistula X 2 yrs,\n Hip C_>pegasysx X 48 weeks(dx ), AS( 1.0cm2 ), Mod AI,\n Secondary hyperparathyroidism, Lumbago on methadone, S/P\n pericardiocentesis, pericardial window with uremic pericarditis at VA yrs ago. One episode of hemoptysis_> liver/GB US\n unremarkable. ? Emphysema and RLL pneumonia by Chest CT \n Surgery / Procedure and date: -AVR 27mm mosaic tissue\n valve-EZ tube. Preop TTE with 50% EF, OR TEE-EF 15% pre/post. No probs\n on pump. OFF with multiple shocks (not responsive to neo) initially\n paced. Then epi .03, pit 4u/hr, levo .2. Fem A line placed r/t ?BP with\n radial. TD CO 6.0-Echo-3.2. CCO swan placed at end. Vanco/cipro 10am.\n 2L cryst, 2u PRBC's, 500cc cell , no UO. Had HD today . BP-104\n min, XC-78 min. Out prop 50,pit 4u/hr,epi .03, and levo .03. In SR\n 80's with PVC's.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:75\n Temperature:\n 98.6\n Arterial BP:\n S:96\n D:58\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 759 mL\n 24h total out:\n 375 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.6 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 8 mA\n Temporary atrial stimulation setting:\n 16 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular stimulation threshold :\n 5 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 03:02 AM\n Potassium:\n 5.9 mEq/L\n 07:30 AM\n Chloride:\n 102 mEq/L\n 03:02 AM\n CO2:\n 25 mEq/L\n 03:02 AM\n BUN:\n 29 mg/dL\n 03:02 AM\n Creatinine:\n 5.9 mg/dL\n 03:02 AM\n Glucose:\n 93 mg/dL\n 03:02 AM\n Hematocrit:\n 26.0 %\n 03:02 AM\n Finger Stick Glucose:\n 178\n 02:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: watch and ring in hospital safe.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CC794\n Transferred to: 6\n Date & time of Transfer: 1500\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n A+O x\ns 3. MAE x\ns 4. Pain controlled well\n NSR w/o ectopy w/intermittent A pacing @ rate 60. VSS. Metoprolol 25\n po BID, Lisinopril started last evening. 2 CT draining serosang minimal\n amt. Has 2 A and 2 V Epicardial wires. Drsg .\n Breath sounds clear, O2 3L/min per NC. Productive cough dark tan yellow\n Abd soft w/active BS.\n FSG > 120\n Action:\n Percocet PRN for pain mngt.\n Pulmonary toilet, O2 weaned to 2 L. CT dc\n OOB to chair\n Diet advanced\n RSSI sq per protocol\n Response:\n Good effect from Percocet\n Sats 93% or >. No resp distress noted, = rise and fall of chest.\n Transfers w/standby assist\n Tolerates diet\n FSG > 175\n Plan:\n Pulmonary toilet, mobilize, monitor, tx, support, and comfort. Dc to\n home by mid week.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Minimal HUO via Foley\n BUN 29/Creatinine 5.9\n K 6.1, Phos 6.3\n Action:\n K rechecked\n Phos binding drugs ordered and initiated\n Response:\n K on recheck = 5.9\n Plan:\n HD today 2 hr run\n" }, { "category": "Nursing", "chartdate": "2162-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554313, "text": "HD8\n POD #1\n 60 yo M s/p AVR (#27mm tissue valve )-\n PMH: ESRD on HD (MWF), bicuspid AV w/AS, AI, HTN, hip C(s/p Pegasysx\n 48wks), HTN, ^ chol, Hyperhomocysteinemia, Secondary\n hyperparathyroidism, Lumbago-methadone, Anemia.\n Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Lightly sedated on propofol able to nod head yes/no to\n questions. MAE x\ns 4 to command. Stable hemodynamics on levo and Epi.\n Epicardial wires. 2 Mediastinal chest tube. Right fem and radial A\n lines. RIJ cordis w/CCO swan. Generalized puffy edema. NSR -> ST\n w/freq PACs.\n Intubated on Vent. Breath sounds clear.\n Abd soft w/act BS, OG tube to sx\n Foley cath patent\n Insulin gtt for glucose mngt\n IC 1.10\n Action:\n Propofol weaned off. Percocet for pain mngt\n Epi and Levo weaned off, CCO dc\nd. CT to 20cm sx. Fem A line\n dc\nd. Amiodarone po started. Metoprolol 12.5 mg po started after 1 time\n dose of IV 5 mg. Wires checked\n Extubated to NC 3 L/min. Pulmonary toilet.\n OG tube dc\nd. Taking sips and chips and PO meds\n Insulin gtt weaned off\n Ca+ gluc 2 gm\n Response:\n A+O x\ns 3. MAE x\ns 4, noodle like legs when getting OOB.\n Good effect from percocet.\n Hemodynamics remain stable. NSR w/o ectopy sense metoprolol\n IV. Both A and V wires sense and capture appropriately. HTN this\n afternoon tx w/metoprolol.\n Sats 95% or >. No resp distress noted, = rise and fall of\n chest. Pulls ~ 800 ml w/ IS. CT dumps 100 cc after getting OOB\n Tolerating meds and sips/chips w/o difficulties.\n FSG <120\n Plan:\n Pulmonary toilet. Mobilize, monitor, tx, support, and\n comfort. Txfr to 6 tomorrow. ^ po metoprolol and begin prn\n hydralazine for bp mngt\n" }, { "category": "Nursing", "chartdate": "2162-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554484, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n A+O x\ns 3. MAE x\ns 4. Pain controlled well\n NSR w/o ectopy w/intermittent A pacing @ rate 60. VSS. Metoprolol 25\n po BID, Lisinopril started last evening. 2 CT draining serosang minimal\n amt. Has 2 A and 2 V Epicardial wires. Drsg .\n Breath sounds clear, O2 3L/min per NC. Productive cough dark tan yellow\n Abd soft w/active BS.\n FSG > 120\n Action:\n Percocet PRN for pain mngt.\n Pulmonary toilet, O2 weaned to 2 L. CT dc\n OOB to chair\n Diet advanced\n RSSI sq per protocol\n Response:\n Good effect from Percocet\n Sats 93% or >. No resp distress noted, = rise and fall of chest.\n Transfers w/standby assist\n Tolerates diet\n FSG > 175\n Plan:\n Pulmonary toilet, mobilize, monitor, tx, support, and comfort. Dc to\n home by mid week.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Minimal HUO via foley\n BUN 29/Creatinine 5.9\n K 6.1, Phos 6.3\n Action:\n K rechecked\n Phos binding drugs ordered and initiated\n Response:\n K on recheck = 5.9\n Plan:\n HD today 2 hr run\n" }, { "category": "Nursing", "chartdate": "2162-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554265, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Lightly sedated on propofol able to nod head yes/no to questions. MAE\n x\ns 4 to command. Stable hemodynamics on levo and epi. Epicardial\n wires. 2 Mediastinal chest tube. Right fem and radial A lines. RIJ\n cordis w/CCO swan. Generalized puffy edema. NSR -> ST w/freq PACs.\n Intubated on Vent. Breath sounds clear.\n Abd soft w/act BS, OG tube to sx\n Foley cath patent\n Insulin gtt for glucose mngt\n IC 1.10\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2162-01-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554160, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Respiratory Care Shift Procedures\n Bedside Procedures: Respiratory rate increased to 18 to compensate for\n respiratory acidosis. Repeat abg results on the current settings\n revealed a normal acid-base balance with a compensated, very mild,\n respiratory acidosis with adequate oxygenation. No RSBI measured due\n to lack of spontaneous respiration.\n" }, { "category": "Physician ", "chartdate": "2162-01-24 00:00:00.000", "description": "ICU Note - CVI", "row_id": 554448, "text": "CVICU\n HPI:\n HD9\n POD #2\n 60 yoM s/p AVR (#27mm tissue valve )-\n EF 15% CR WT HgA1c\n PMH: ESRD on HD (MWF), bicuspid AV w/AS, AI, HTN, hep C(s/p Pegasysx\n 48wks), HTN, ^chol, Hyperhomocysteinemia, Secondary\n hyperparathyroidism, Lumbago-methadone, Anemia.\n CURRENT MEDS: Epo @ HD, ASA 81', Sensipar 120', Docusate 100\", Flomax\n .8', Lisinopril 20\", Methadone 10''', Protonix 40\",Renagel 800''',\n Dialyvite 800, Lipitor 80'\n - extubated. Plan HD :\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen . Amiodarone . Aspirin . Atorvastatin . Calcium\n Gluconate. Cinacalcet . Docusate Sodium . Insulin . Lisinopril .\n Magnesium Sulfate . Metoclopramide . Metoprolol Tartrate . Milk of\n Magnesia . Morphine Sulfate . Nephrocaps . Nicotine Patch .\n Oxycodone-AcetaminophnPantoprazol Tamsulosin. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:30 AM\n EXTUBATION - At 10:37 AM\n weaned and extubated at 1037 am to 3L O2 via nasal cannula.\n INVASIVE VENTILATION - STOP 10:45 AM\n CCO PAC - STOP 12:30 PM\n Post operative day:\n POD#2 - S/P AVR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:25 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 11:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37\nC (98.6\n HR: 60 (60 - 101) bpm\n BP: 128/76(90) {114/63(77) - 148/85(97)} mmHg\n RR: 16 (14 - 25) insp/min\n SPO2: 95%\n Heart rhythm: A Paced\n Height: 67 Inch\n CVP: 16 (9 - 20) mmHg\n PAP: (51 mmHg) / (26 mmHg)\n CO/CI (CCO): () / (4.3 L/min/m2)\n SvO2: 67%\n Total In:\n 3,361 mL\n 483 mL\n PO:\n 240 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 3,011 mL\n 123 mL\n Blood products:\n Total out:\n 528 mL\n 295 mL\n Urine:\n 188 mL\n 175 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 2,833 mL\n 188 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 112 K/uL\n 9.2 g/dL\n 93 mg/dL\n 5.9 mg/dL\n 25 mEq/L\n 5.9 mEq/L\n 29 mg/dL\n 102 mEq/L\n 135 mEq/L\n 26.0 %\n 8.2 K/uL\n [image002.jpg]\n 04:08 PM\n 04:45 PM\n 06:07 PM\n 06:17 PM\n 08:14 PM\n 11:11 PM\n 02:50 AM\n 03:30 AM\n 10:08 AM\n 03:02 AM\n WBC\n 13.3\n 10.1\n 8.1\n 8.2\n Hct\n 21\n 22.7\n 29.3\n 25.6\n 27.7\n 26.0\n Plt\n 134\n 119\n 121\n 112\n Creatinine\n 3.8\n 4.1\n 5.9\n TCO2\n 32\n 30\n 28\n 28\n 24\n Glucose\n 96\n 89\n 75\n 84\n 85\n 85\n 81\n 93\n Other labs: PT / PTT / INR:16.5/36.4/1.5, Differential-Neuts:79.6 %,\n Lymph:14.8 %, Mono:2.8 %, Eos:2.4 %, Fibrinogen:282 mg/dL, Lactic\n Acid:2.4 mmol/L, Ca:9.9 mg/dL, Mg:3.7 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR), RENAL FAILURE, END STAGE\n (END STAGE RENAL DISEASE, ESRD)\n Assessment and Plan: Stable CV. K to 6.1/5.9 therefor to be dialyzed\n today then to F6. Cts out.\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: HD\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n 20 Gauge - 10:42 AM\n Prophylaxis:\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Rehab Services", "chartdate": "2162-01-24 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 554462, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 424 / AVR\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: Pt is a 60 y/o m\n with ESRD on HD with AS, AI, HTN, Hep C who presented to OSH on \n with substernal chest pain x 4 hours. Given Dilt, carotid massage and\n troponin of 1.04, transferred to . Pt underwent AVR on ,\n XCT 78.\n Past Medical / Surgical History: ESRD on HD, Hep C, AS, Mod AI,\n hyperparathyroidism, s/p pericardiocentesis\n Medications:\n Radiology:\n Labs:\n 26.0\n 9.2\n 112\n 8.2\n [image002.jpg]\n Other labs:\n Activity Orders: Advance per cardiac rehabilitation guidelines\n Social / Occupational History: Retired from construction, 1 PPD x 45\n years\n Living Environment: Lives with wife, 5 stairs to enter\n Prior Functional Status / Activity Level: Independent ambulation, ADLs,\n Drives self to HD (M,W,F)\n Objective Test\n Arousal / Attention / Cognition / Communication: A+Ox3, pleasant and\n cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 62\n 128/74\n 16\n 94% 2L\n Rest\n /\n Sit\n 65\n 141/81\n 15\n 94% 2L\n Activity\n /\n Stand\n 73\n 125/61\n 16\n 92% 2L\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Normal symmetric pattern, cough strong and\n productive, diminished at bases\n Integumentary / Vascular: Strenotomy c/d/i, foley intact, pacing wires,\n palpable pedal pulses\n Sensory Integrity: Intact to LT throughout\n Pain / Limiting Symptoms: Denies pain throughout session 0/10\n Posture: Rounded shoulders, protracted scapulae\n Range of Motion\n Muscle Performance\n WNL UEs and \n throughout\n Motor Function: No abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Instructed in log roll technique supine to sit, able\n to perform with cues. Stood with supervision without use of UEs.\n Ambulated 50 ft pushing wheelchair with supervision, stable aerobic and\n hemodynamic response throughout activity.\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n T\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n Ambulation:\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: No gross LOB ambulating pushing w/c\n Education / Communication: Educated pt on role and goal of PT,\n initiated education on sternal precautions, activity guidelines,\n walking program and importance of pacing, referred to outpatient\n cardiac rehab. Communicated pt status with RN.\n Intervention:\n Other:\n Diagnosis:\n Impaired Functional Mobility\n Knowledge deficit re. activity guidelines / sternal precautions\n Impaired aerobic capacity\n Clinical impression / Prognosis: Pt is a 60 y/o m s/p AVR. Pt p/w above\n impairments c/w CV pump dysfunction. Pt demonstrated excellent\n potential to return to independance with PT intervention. Initiated\n education, pt will require reinforcement. Anticipate d/c home in 1 PT\n f/u on POD #4.\n Goals\n Time frame: 1 PT visit (POD #4)\n 1.\n Independent log roll supine to sit\n 2.\n Independent ambulation 500 ft without AD, no LOB, with stable aerobic\n response\n 3.\n Independent up/down 5 stairs\n 4.\n Demonstrate knowledge of sternal precautions with 100% mobility\n 5.\n Tolerate 100% activity on RA O2>90%\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1 PT visit\n Pt education\n Gait training\n Stair assessment\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Rehab Services", "chartdate": "2162-01-24 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 554464, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 424 / AVR\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: Pt is a 60 y/o m\n with ESRD on HD with AS, AI, HTN, Hep C who presented to OSH on \n with substernal chest pain x 4 hours. Given Dilt, carotid massage and\n troponin of 1.04, transferred to . Pt underwent AVR on ,\n XCT 78.\n Past Medical / Surgical History: ESRD on HD, Hep C, AS, Mod AI,\n hyperparathyroidism, s/p pericardiocentesis\n Medications:\n Radiology:\n Labs:\n 26.0\n 9.2\n 112\n 8.2\n [image002.jpg]\n Other labs:\n Activity Orders: Advance per cardiac rehabilitation guidelines\n Social / Occupational History: Retired from construction, 1 PPD x 45\n years\n Living Environment: Lives with wife, 5 stairs to enter\n Prior Functional Status / Activity Level: Independent ambulation, ADLs,\n Drives self to HD (M,W,F)\n Objective Test\n Arousal / Attention / Cognition / Communication: A+Ox3, pleasant and\n cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 62\n 128/74\n 16\n 94% 2L\n Rest\n /\n Sit\n 65\n 141/81\n 15\n 94% 2L\n Activity\n /\n Stand\n 73\n 125/61\n 16\n 92% 2L\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Normal symmetric pattern, cough strong and\n productive, diminished at bases\n Integumentary / Vascular: Strenotomy c/d/i, foley intact, pacing wires,\n palpable pedal pulses\n Sensory Integrity: Intact to LT throughout\n Pain / Limiting Symptoms: Denies pain throughout session 0/10\n Posture: Rounded shoulders, protracted scapulae\n Range of Motion\n Muscle Performance\n WNL UEs and \n throughout\n Motor Function: No abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Instructed in log roll technique supine to sit, able\n to perform with cues. Stood with supervision without use of UEs.\n Ambulated 50 ft pushing wheelchair with supervision, stable aerobic and\n hemodynamic response throughout activity.\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n T\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n Ambulation:\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: No gross LOB ambulating pushing w/c\n Education / Communication: Educated pt on role and goal of PT,\n initiated education on sternal precautions, activity guidelines,\n walking program and importance of pacing, referred to outpatient\n cardiac rehab. Communicated pt status with RN.\n Intervention:\n Other:\n Diagnosis:\n Impaired Functional Mobility\n Knowledge deficit re. activity guidelines / sternal precautions\n Impaired aerobic capacity\n Clinical impression / Prognosis: Pt is a 60 y/o m s/p AVR. Pt p/w above\n impairments c/w CV pump dysfunction. Pt demonstrated excellent\n potential to return to independance with PT intervention. Initiated\n education, pt will require reinforcement. Anticipate d/c home in 1 PT\n f/u on POD #4.\n Goals\n Time frame: 1 PT visit (POD #4)\n 1.\n Independent log roll supine to sit\n 2.\n Independent ambulation 500 ft without AD, no LOB, with stable aerobic\n response\n 3.\n Independent up/down 5 stairs\n 4.\n Demonstrate knowledge of sternal precautions with 100% mobility\n 5.\n Tolerate 100% activity on RA O2>90%\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1 PT visit\n Pt education\n Gait training\n Stair assessment\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2162-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554356, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt alert and oriented, hypertensive sbp 150\ns. lungs clear , strong\n productive cough. Creatinine and K rising this AM. States has pain in\n chest on cough/deep breathe, reluctant to take medication. Declines\n to remain on side in bed d/t back pain, willing to turn occasionally.\n Minimal chest tube drainage overnoc. A and v wires functional.\n Occasional pacing noted. States feeling nicotine withdrawal.\n Tolerated jello PO.\n Action:\n Monitored, Lisinopril added for blood pressure management. Added\n nicotine patch. Pain management with Percocet PO, morphine IV x1 dose\n in eve to catch up to pain level. Encouraged to cough/deep breathe.\n Response:\n Good pain relief, willing to cough and deep breathe. States feeling\n better with nicotine patch. Blood pressure stable 120\ns-130\n overnoc. Occasional pacing noted with increased Metoprolol dose.\n Plan:\n Continue to monitor, continue pain control, pulm hygiene, encourage\n PO\ns, OOB to chair. ?d/c a line and transfer to floor.\n" }, { "category": "Nursing", "chartdate": "2162-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554424, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n A+O x\ns 3. MAE x\ns 4. Pain controlled well\n NSR w/o ectopy w/intermittent A pacing @ rate 60. VSS. Metoprolol 25\n po BID, Lisinopril started last evening. 2 CT draining serosang minimal\n amt. Has 2 A and 2 V Epicardial wires. Drsg .\n Breath sounds clear, O2 3L/min per NC.\n Abd soft w/active BS.\n FSG > 120\n Action:\n Percocet PRN for pain mngt.\n Pulmonary toilet, O2 weaned. CT dc\n OOB to chair\n Diet advanced\n RSSI sq per protocol\n Response:\n Good effect from Percocet\n Sats 93% or >. No resp distress noted, = rise and fall of chest.\n Tolerates diet\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Minimal HUO via foley\n BUN 29/Creatinine 5.9\n K 6.1, Phos 6.3\n Action:\n K rechecked\n Phos binding drugs ordered\n Response:\n K on recheck =\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554440, "text": "Valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n A+O x\ns 3. MAE x\ns 4. Pain controlled well\n NSR w/o ectopy w/intermittent A pacing @ rate 60. VSS. Metoprolol 25\n po BID, Lisinopril started last evening. 2 CT draining serosang minimal\n amt. Has 2 A and 2 V Epicardial wires. Drsg .\n Breath sounds clear, O2 3L/min per NC. Productive cough dark tan.\n Abd soft w/active BS.\n FSG > 120\n Action:\n Percocet PRN for pain mngt.\n Pulmonary toilet, O2 weaned to 2 L. CT dc\n OOB to chair\n Diet advanced\n RSSI sq per protocol\n Response:\n Good effect from Percocet\n Sats 93% or >. No resp distress noted, = rise and fall of chest.\n Tolerates diet\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Minimal HUO via foley\n BUN 29/Creatinine 5.9\n K 6.1, Phos 6.3\n Action:\n K rechecked\n Phos binding drugs ordered and initiated\n Response:\n K on recheck = 5.9\n Plan:\n HD today\n" }, { "category": "Radiology", "chartdate": "2162-01-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1058614, "text": " 6:17 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for CHF, other intrathoracic pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with paroxysmal SOB, elevated BNP\n REASON FOR THIS EXAMINATION:\n assess for CHF, other intrathoracic pathology\n ______________________________________________________________________________\n WET READ: JXRl SAT 7:45 AM\n - ill defined opacity RLL probable pneumonia, but may be due to overlying\n prominent vessels/interstitum (no recent priors available)\n - small b/l effusions\n - interstitial prominence suggestive of pulm edema\n - COPD.\n WET READ VERSION #1 JXRl SAT 7:44 AM\n - ill defined opacity LLL probable pneumonia, although may be due to\n overlying prominent vessels/interstitum (no recent priors available)\n - small b/l effusions\n - interstitial prominence suggestive of pulm edema\n - COPD\n WET READ VERSION #2 JXRl SAT 7:44 AM\n - ill defined opacity RLL probable pneumonia, but may be due to overlying\n prominent vessels/interstitum (no recent priors available)\n - small b/l effusions\n - interstitial prominence suggestive of pulm edema\n - COPD\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old male with paroxysmal shortness of breath and elevated\n BNP.\n\n COMPARISON: Chest x-ray .\n\n CHEST, TWO VIEWS: The lungs are markedly hyperinflated. There are small\n bilateral pleural effusions. The interstitium is prominent, and chronicity is\n difficult to assess without recent prior studies.\n\n Ill-defined relative opacity of the right lower lobe may correspond to\n prominent interstitium and overlapping vessels, but pneumonia cannot be\n excluded. The cardiac silhouette is enlarged. There are atherosclerotic\n calcifications of the aortic arch.\n\n IMPRESSION:\n 1. Hyperinflation consistent with chronic lung disease.\n 2. Small bilateral pleural effusions.\n 3. Interstitial pulmonary edema.\n 4. Probable right lower lobe pneumonia.\n (Over)\n\n 6:17 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for CHF, other intrathoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-01-20 00:00:00.000", "description": "CT CHEST W&W/O C", "row_id": 1059342, "text": " 4:28 AM\n CT CHEST W&W/O C Clip # \n Reason: eval aorta for possible aortic valve replacement/ and eval f\n Admitting Diagnosis: S/P VTACH\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Hep C, ESRD on HD, AS, CHF, CAD presents with NSTEMI,\n severe AS and ? RLL pna on CXR. Evaluation for AS replacement\n REASON FOR THIS EXAMINATION:\n eval aorta for possible aortic valve replacement/ and eval for possible RLL pna\n seen on CXR. Also please coordinate time and perform prior to dialysis. Pt\n scheduled for dialysis tomorrow .\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi WED 5:29 AM\n Small bilateral effusions. Severe emphysematous changes. Aortic valve\n calcifications. Bibasilar peribronchovascular opacities likely relate to edema\n but infection cannot be excluded. no pe or dissection\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: Patient with NSTEMI, severe AS, question pneumonia in the\n right lower lobe.\n\n TECHNIQUE: Multidetector CT through the chest was acquired without IV\n contrast. 5-, 1.25-mm collimation images, sagittal and coronal reformations\n were provided and reviewed.\n\n FINDINGS: The airways are patent to the subsegmental level. Calcification in\n the aortic valve is severe, moderate calcification is in the mitral annulus,\n dense calcification is in the LAD, moderate calcification is in the right\n coronary artery. Cardiac size is top normal, bilateral pleural effusions are\n small greater on the right side, there is mild calcification of the aortic\n wall in the arch, there is no calcification in the ascending aorta, minimal\n calcification is in the descending aorta medially, enlarged mediastinal lymph\n nodes measure in the right upper paratracheal station 14 mm, in right lower\n paratracheal station 13 mm, in the subcarinal station 19 mm, evaluation of\n hilar lymphadenopathy is limited due to lack of IV contrast\n\n This examination is not tailored for subdiaphragmatic evaluation. Of note the\n suprarenal abdominal aorta measures up to 32 mm AP and has dense wall\n calcifications. There is vicarious excretion of contrast in the gallbladder.\n The kidneys are small, show multiple hypodense cortical lesions, small to be\n characterized, likely cysts. On the right there also appear to be parapelvic\n cysts, this evaluation is limited due to the lack of IV contrast. Dense\n calcification is in the celiac artery, SMA and splenic artery.\n\n 2-mm nodule in the left upper lobe (3:20) is not calcified, a calcified\n granuloma is in the left upper lobe (7:75), two non-calcified less than 3 mm\n nodules are in the left upper lobe (7:81 and 82), noncalcified elongated\n nodule in the left upper lobe measures 3.8 mm (7:96), tiny granuloma is in the\n (Over)\n\n 4:28 AM\n CT CHEST W&W/O C Clip # \n Reason: eval aorta for possible aortic valve replacement/ and eval f\n Admitting Diagnosis: S/P VTACH\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left upper lobe (7:106), 3- mm nodule in the left upper lobe is noncalcified\n (7:147), 5.8-mm nodule in the left lower lobe is noncalcified (7: 209), 3-mm\n noncalcified nodule is in the right upper lobe (7:113), 4-mm nodule in the\n right middle lobe is noncalcified (7:171).\n\n Moderate centrilobular emphysema is located in the upper lobes. A focal area\n of ground-glass opacity in the posterior segment of the right upper lobe is\n associated with bronchial wall thickening, small areas of peribronchial\n consolidation and peribronchial ground-glass opacities in the lower lobes\n bilaterally. There is mild interlobular smooth septal thickening in the bases\n bilaterally.\n\n There are no bony findings of malignancy. Degenerative changes and compression\n fractures are in the lower thoracic spine and L1.\n\n IMPRESSION:\n 1. Multifocal infectious process, these abnormalities also could be due to\n aspiration.\n 2. Small bilateral pleural effusion.\n 3. Mediastinal and bilateral hilar lymphadenopathy that is greater on the\n right hilum measuring up to 11 mm in the right hilum, is reactive.\n 4. Severe aortic valve calcifications. Emphysema.\n 5. Multiple calcified and noncalcified less than 5 mm nodules, follow up is\n recommended in three months.\n\n" }, { "category": "Radiology", "chartdate": "2162-01-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1059994, "text": " 7:07 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: S/P VTACH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with s/p AVR - please with x-ray results if\n there is concern\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax.\n\n Single portable radiograph of the chest demonstrates the patient to be status\n post median sternotomy, new when compared with . There is a\n nasogastric tube present with its tip in the stomach. The proximal side port\n of the nasogastric tube is at the level of the gastroesophageal junction. The\n nasogastric tube should be advanced. There is an endotracheal tube present\n with its tip located just below the level of the clavicular heads. There is a\n right internal jugular Swan-Ganz catheter with its tip in the right pulmonary\n artery. Two mediastinal drains are identified. No pneumothorax or\n pneumomediastinum is evident. The costophrenic angles are blunted\n bilaterally. There is increased airspace opacity involving both lungs.\n Trachea is midline.\n\n IMPRESSION:\n\n Interval median sternotomy.\n\n Nasogastric tube with the proximal side port at the level of the\n gastroesophageal junction. The nasogastric tube should be advanced. The\n remaining support lines are in place.\n\n Moderate pulmonary edema and small bilateral pleural effusions.\n\n The multiple tiny pulmonary nodules seen on CT exam of are not\n evident on the current radiograph. Similarly, the bilateral lower lobe\n bronchiectasis and ground-glass opacities seen on previous CT examination are\n not readily identified on the current radiograph and could be obscured by the\n overlying pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-01-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1058786, "text": " 10:36 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: ? cirrhosis and venous patency\n Admitting Diagnosis: S/P VTACH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with known hepatitis C now with upper GI bleeding. Please\n perform RUQ ultrasound with dopplers to assess for cirrhosis and venous\n patency.\n REASON FOR THIS EXAMINATION:\n ? cirrhosis and venous patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known hepatitis C, now with upper GI bleeding, assess for\n cirrhosis and venous patency.\n\n COMPARISON: None available.\n\n ABDOMINAL ULTRASOUND: -scale and color Doppler son images were\n obtained that demonstrate the liver to be of coarsened echotexture, but\n without focal hepatic lesion. There is no ascites. Limited views of the\n gallbladder appear normal, and the common bile duct measures between 3.5 and\n 4.6 mm. The right kidney is small, echogenic and contains cysts. Limited\n views of the pancreas and aorta are within normal limits. The left kidney\n measures 7.3 cm and contains small cysts. The spleen is normal in terms of\n echotexture and measures to 11.9 cm.\n\n DOPPLER ULTRASOUND: Hepatic veins demonstrate hepatofugal and wall-to-wall\n flow with normal waveform. Main portal venous flow is hepatopetal and of\n normal velocity. Anterior and posterior right portal vein flow is a\n hepatopetal and normal in velocity. Flow in the hepatic artery demonstrates a\n brisk upstroke and normal resistive index of 0.78. Flow in the splenic vein\n is normal.\n\n IMPRESSION:\n 1. Slightly coarsened echotexture of the liver.\n\n 2. Patent portal venous and hepatic veins with normal flow in terms of\n directions and velocity.\n\n 3. Main hepatic artery normal in terms of waveform.\n\n 4. Bilaterally small kidneys consistent with chronic renal disease\n\n" }, { "category": "Radiology", "chartdate": "2162-01-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060173, "text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx after CT removal\n Admitting Diagnosis: S/P VTACH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with\n REASON FOR THIS EXAMINATION:\n ? ptx after CT removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal.\n\n A single portable radiograph of the chest demonstrates interval removal of the\n support lines seen on . There are bilateral pleural effusions,\n likely slightly worse when compared to the previous exam. Increased airspace\n opacities involving both lungs persist and may be slightly improved in the\n interval. There is a tiny right apical pneumothorax. Sternotomy wires are\n intact and the cardiomediastinal contours are unchanged.\n\n IMPRESSION:\n\n Interval removal of support lines.\n\n Tiny right apical pneumothorax.\n\n Persistent CHF.\n\n\n" }, { "category": "ECG", "chartdate": "2162-01-22 00:00:00.000", "description": "Report", "row_id": 190117, "text": "Normal sinus rhythm at 90 beats per minute. Left bundle-branch block with\nsecondary ST-T wave changes. Compared to the previous tracing of \nno diagnostic interval change. The ST segment elevation in the right-sided\nprecordial leads is similar and unchanged from tracings performed on ,\n and .\n\n" }, { "category": "ECG", "chartdate": "2162-01-18 00:00:00.000", "description": "Report", "row_id": 190348, "text": "Sinus rhythm at upper limits of normal rate. Left axis deviation.\nLeft bundle-branch block. Since the previous tracing of the\nrate is faster.\n\n" }, { "category": "ECG", "chartdate": "2162-01-17 00:00:00.000", "description": "Report", "row_id": 190349, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof there is no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2162-01-16 00:00:00.000", "description": "Report", "row_id": 190350, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2162-01-16 00:00:00.000", "description": "Report", "row_id": 190351, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof left bundle-branch block is new.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2162-01-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1060509, "text": " 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u ptx and effusions\n Admitting Diagnosis: S/P VTACH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n f/u ptx and effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup of lung changes.\n\n FINDINGS: The pre-existing right-sided apical pneumothorax is no longer seen.\n The pre-existing bilateral pleural effusions show slightly different\n distribution but unchanged overall extent. The pre-existing bilateral\n parenchymal opacities have mildly decreased in extent. Also decreased has a\n subtle opacity at the bases of the right upper lobe.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2153-05-06 00:00:00.000", "description": "Report", "row_id": 1625266, "text": "TSICU NPN 0700-1900\nEVENTS:\n\n- Arterial line placed this am\n\n- Extubated at 1200\n\n\nREVIEW OF SYSTEMS:\n\nNEURO: Pt A&OX2-3, confused at times. Pupils equal and reactive. Following all commands. Moving all extremities. CIWA scale, ativan given PRN. +tremors noted post extubation. Head CT planned for MN tonight.\n\nRESP: Extubated this afternoon. NT suctioned for moderate amts thick white secretions. Pt placed on high flow neb with SATS >95%. Pt weaned to 2L NC by this evening with SATS 97%. LS clear throughout. Strong cough.\n\nCV: SR 80-100's, no ectopy noted. Home BP meds started this afternoon. Left radial arterial line placed this am. PIV X 2. Lytes repleted throughout shift. Potassium, K-phos, magnesium and calcium all repleted.\n\nENDO: No RISS ordered, BS WNL.\n\nID: TMAX 100.0. MRSA admission swabs sent.\n\nGI: Abd soft, non-distended. Pt tolerating clear liquids this evening. No stool.\n\nGU: Foley draining clear yellow urine. Adequtae UO.\n\nSKIN: Small degloving injury to right hand, irrigated and covered with DSD. RLE with puncture wound, irrigated by TSICU HO and suture placed. Left eyebrow with sutures intact. Backside intact.\n\nSOCIAL: No contact from family.\n\nPLAN: Continue to monitor neuro checks Q2/hr. Repeat head CT tonight at MN. Continue CIWA scale, give ativan as needed. Monitor lytes. Social work c/s tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2153-05-06 00:00:00.000", "description": "Report", "row_id": 1625264, "text": "resp care\nPt transferred from ew and placed on a/c 500x18 100% 5peep. Fio2 weaned to 50% with sats of 100%. ABG obtained and revealed a resp alkalosis.Currently pt is on a/c 500x14 40% 5peep. BS coarse bil.Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2153-05-07 00:00:00.000", "description": "Report", "row_id": 1625267, "text": "1900-0700\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nNEURO: PT A&O X3. DISCUSSION WITH PT AT COMMENCEMENT OF SHIFT REVEALED THAT PT HAS BEEN THROUGH ALCOHOL WITHDRAWAL BEFORE. HE STATED HE SAW LITTLE BUGS AND FELT SHAKY. OVERNIGHT HAS BEEN CONTINUED ON CIWA SCALE WITH 2MG IV LORAZEPAM GIVEN 3 TIMES ALONG WITH LORAZEPAM STANDING DOSE OF 1MG IV Q6. REMAINED ORIENTED X3- TIME, PLACE, SELF. PT DID STATE HE COULD SEE MILK CARTONS AND A BABY RHINO BUT KNEW THEY WEREN'T THERE. COMPLIANT WITH CARE AND RESTED WELL OVERNIGHT. Q2HR NEURO CHECKS CONTINUE.\n\nCV: ALINE REMOVED ACCIDENTALLY BY PT THIS AM. SBP 130-145. HR SR 60'S-70'S. NO ECTOPY NOTED.\n\nRESP: NC 02 2L. DESATS TO 93% ON RA WHEN SLEEPING. LS CLEAR THROUGHTOUT. PT HAS STRONG NON PRODUCTIVE COUGH.\n\nGI/GU: FOLEY DRAINING GOOD VOLUMES OF CLEAR YELLOW URINE. TOLERATING CLEAR LIQUIDS WELL. + BOWEL SOUNDS. NO MOVEMENT.\n\nSKIN: 3 STAPLES PLACED IN WOUND TO R ARM AND COLLAR REMOVED BY MD. REMAINS C&D.\n\nSOCIAL: WHEN ASKED IF PT WISHED FOR ANY FAMILY OR FRIENDS TO BE CONTACT HE SAID HE DID NOT WANT ANYONE CALLED. HE DID SAY HE HAS A BROTHER AND A THERAPIST AND HE CALL HIS THERAPIST TODAY-MONDAY.\n\nPLAN: CONTINUE CIWA.\n ? Q4HR NEURO CHECKS.\n ? TX TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2153-05-06 00:00:00.000", "description": "Report", "row_id": 1625265, "text": "0500-0700\nADMISSION NOTE\n\n46YR OLD MALE FOUND DOWN IN UNKNOWN CIRCUMSTANCES. ETOH 516. ALERT ON ADMISSION BUT BECAME COMBATIVE. INTUBATED FOR CT WHICH SHOWED- SMALL L PARIETAL SAH AND L TEMPORAL/PARIETAL IPH. LACERATION TO L EYE-SUTURED. ? PUNCTURE/STAB WOUND TO LOWER R ARM-YET TO BE TREATED.\n\nPMH: HTN\n SDH-\n\nNKDA\n\nFULL CODE\n\nNEURO: PT SEDATED ON PROPOFOL-LIGHTENED FOR NEURO CHECK. PT FOLLOWED COMMANDS ON 10MCGS PROPOFOL. WIGGLED TOES. SQUEEZED HANDS. STUCK OUT TONGUE. NODDED HEAD TO QUESTION. T 95.1 ON ADMISSION. WARMING SLOWLY.\n\nCV: HR SR 60'S. SBP 85-115. 400ML NS FLUID BOLUS GIVEN FOR SBP 83 WITH GOOD EFFECT. PROPOFOL DOSE REDUCED. LABS SENT. K 2.6-TO BE REPLETED-PIV'S ONLY. MD TO PLACE OG/NGT.\n\nRESP: LS CLEAR. ? VOMIT NOTED IN NASAL PASSAGES. ? ASPIRATION. SEE RT NOTE FOR VENT SETTINGS/ABG. BEARD SHAVED TO ENSURE SECURE TAPING OF ETT.\n\nGI: + BOWEL SOUNDS. IV FLUID NS 100ML NOW CHANGED TO MVI. BS 118 ON ADMISSION.\n\nGU: AMBER URINE VIA FOLEY.\n\nSKIN: LACERATION TO L EYEBROW NOW SUTURED. TIP OF FINGER ON L HAND CUT ? SUTURE REQUIRED. R LOWER ARM ? PUNCTURE/STAB TYPE WOUND. FRACTURE R/O. TREATMENT YET TO BE DONE FOR THIS. REMAINING SKIN APPEARS INTACT. J COLLAR IN PLACE. COLLAR CARE DONE.\n\nSOCIAL: PT IS DOCUMENTED AS HAVING A BROTHER BUT NO TELEPHONE NUMBER IS AVAILABLE TO US AT THIS TIME.\n\nPLAN: MONITOR HAEMODYNAMICS.\n ? WHEN RPT CT.\n R LOWER ARM WOUND TO BE TREATED BY MD.\n NGT TO BE PLACED.\n REPLETE K.\n" }, { "category": "Radiology", "chartdate": "2153-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018040, "text": " 10:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: for fever\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with small left parietal SAH\n REASON FOR THIS EXAMINATION:\n for fever\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:17 P.M., \n\n HISTORY: Subarachnoid hemorrhage. Fever.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are clear. Heart size is normal. Mediastinal caliber is unchanged\n since when a chest CT showed no significant abnormality. There is no\n pleural effusion or evidence of central adenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-05-06 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1017608, "text": " 12:34 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL INDICATION: Trauma.\n\n COMPARISON: None.\n\n AP SUPINE CHEST X-RAY: Underlying trauma board limits evaluation. The\n cardiomediastinal silhouette is normal, and apparent widening of the\n mediastinum is projectional. The osseous structures are intact.\n\n IMPRESSION: No evidence of fracture. Widening of the mediastinum is\n projectional.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-05-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1017729, "text": " 12:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for interval change (at 6/15 23:59)\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with SAH, IPH\n REASON FOR THIS EXAMINATION:\n assess for interval change (at 6/15 23:59)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 46-year-old man with subarachnoid and intraparenchymal\n hemorrhage, evaluate for change.\n\n COMPARISON: .\n\n NON-CONTRAST CT HEAD: There is scattered hyperdensity along the left sylvian\n fissure along the sulci of the left temporal lobe, consistent with\n subarachnoid hemorrhage, unchanged. A small amount of temporal and parietal\n hemorrhage along the temporal lobe may represent parenchymal or subarachnoid\n hemorrhage, unchanged.\n\n Stable bilateral hypodense subdural collections overlying the left frontal and\n temporal lobes, likely representing hematoma or hygroma. There is also a\n subdural collection along the right frontal convexity measuring up to 5 mm.\n\n The -white matter differentiation is maintained. Soft tissue swelling\n overlying the left orbit is slightly improved. There is no evidence of\n fracture. The paranasal sinuses demonstrate ethmoid thickening, unchanged.\n\n IMPRESSION:\n 1. Stable foci of subarachnoid hemorrhage in the left temporal and parietal\n sulci with possible intraparenchymal hemorrhage.\n\n 2. Bilateral hypodense subdural hematomas versus hygromas are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-05-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1017609, "text": " 12:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SUN 1:53 AM\n Small L parietal subarachnoid hemorrhage and left temporal and parietal\n parenchymal hemorrhage. No subdural hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL INDICATION: 46-year-old man status post fall, rule out bleed.\n\n COMPARISON: Multiple prior head CTs, the most recent dated .\n\n NON-CONTRAST CT HEAD: There is scattered hyperdense foci along the left\n sylvian fissure and along the sulci of the left temporal lobe, consistent with\n subarachnoid hemorrhage. There is also a small amount of temporal and\n parietal apparent intraparenchymal hyperdensity consistent with parenchymal\n hemorrhage or SAH in deep sulci and fissures.\n\n There is a new hypodense subdural collection over the left frontotemporal\n lobes with a maximal thickness of approximately 7 mm consistent with subdural\n hematoma or hygroma. The previously seen right subdural collection has\n resolved.\n\n The - white matter differentiation is maintained. There is a marked amount\n of soft tissue swelling overlying the left upper orbit, without evidence of\n intraorbital abnormality or orbital deformity. There is no evidence of\n fracture. The paranasal sinuses demonstrate mild ethmoid thickening.\n\n IMPRESSION:\n 1. Scattered foci of subarachnoid hemorrhage along the left temporal and\n parietal lobes, with possible intraparenchymal hemorrhage. There is no\n evidence of fracture.\n 2. New left hypodense subdural hematoma versus hygroma measuring 7 mm in\n thickness. Resolution of right subdural collection.\n 3. Moderate amount of soft tissue swelling overlying the subcutaneous soft\n tissues of the left orbit.\n\n" }, { "category": "Radiology", "chartdate": "2153-05-06 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1017610, "text": " 12:45 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD SUN 2:15 AM\n\n No fracture or malalignment to T1.\n\n No fx or malalignment MD\n\n WET READ VERSION #1 DXAe SUN 1:55 AM\n No fracture or malalignment to T1.\n WET READ VERSION #2 DJD SUN 2:15 AM\n No fracture or malalignment to T1.\n\n No fx or malalignment MD\n\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 46-year-old male status post fall, evaluate for injury.\n\n NON-CONTRAST CT C-SPINE:\n\n TECHNIQUE: CT of the cervical spine from the skull base to the T1/2 level\n with multiplanar reformats.\n\n FINDINGS: The patient is intubated, and fluid is seen in the pharynx.\n\n There is no fracture or dislocation. There is no prevertebral soft tissue\n swelling.\n\n At C5/6, there are degenerative changes of the right uncovertebral and facet\n joints causing mild right foraminal stenosis.\n\n The visualized lung apices are clear.\n\n IMPRESSION: No acute fracture or malalignment.\n\n" }, { "category": "Radiology", "chartdate": "2153-05-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1017611, "text": " 12:45 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: S/P FALL\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SUN 1:58 AM\n No fracture, dislocation or evidence of acute trauma.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 46-year-old man status post fall, rule out injury.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired images of the chest, abdomen and pelvis were\n obtained without the administration of oral or IV contrast. Multiplanar\n reformats were reviewed.\n\n COMPARISON: None.\n\n CT CHEST WITHOUT CONTRAST: THe lungs demonstrate scattered atelectesis and are\n otherwise clear. There is no central or axillary lymphadenopathy. Scattered\n mediastinal nodes do not meet CT size criteria for enlargement. There is no\n pleural or pericardial effusion.\n\n CT ABDOMEN WITH IV CONTRAST: Fatty changes in the liver are noted. The\n gallbladder, spleen, pancreas, adrenals are unremarkable. There is a well-\n circumscribed, heterogeneous 2.7 x 2.3 cm mass in the upper pole of the left\n kidney measuring between 30 and 80 Hounsfield units, concerning for neoplastic\n process. The large and small bowel are normal. There is no free fluid or free\n air. There is no retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS: The rectum, sigmoid, bladder are unremarkable.\n\n Bone windows demonstrate no fracture or malalignment.\n\n IMPRESSION:\n 1. No CT evidence of acute trauma.\n\n 2. Heterogeneous mass in the left kidney is concerning for neoplastic\n process, although the differential diagnosis includes hemorrhage. MRI with\n contrast can be obtained for further evaluation\n\n 3. Fatty changes in the liver.\n\n (Over)\n\n 12:45 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: S/P FALL\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2153-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017612, "text": " 12:53 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with intubated 23cm at lip\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 46-year-old man post intubation.\n\n COMPARISON: Study performed 15 minutes ago.\n\n AP SUPINE CHEST: The cardiac size is normal. The lungs are clear, without\n evidence of effusion, infiltrate, or pneumothorax. The osseous structures are\n normal. Slight widening of the mediastinum may be projectional. An\n endotracheal tube terminates in the mid trachea.\n\n IMPRESSION: No acute cardiopulmonary process post intubation.\n\n" }, { "category": "Radiology", "chartdate": "2153-05-06 00:00:00.000", "description": "R FOREARM (AP & LAT) RIGHT", "row_id": 1017613, "text": " 1:29 AM\n FOREARM (AP & LAT) RIGHT Clip # \n Reason: location of fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n location of fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for fracture.\n\n COMAPRISON: None.\n\n AP AND LATERAL VIEWS OF THE RADIUS AND ULNA: There is moderate amount of soft\n tissue swelling overlying the mid right ulna. There is no fracture or\n dislocation. The radiocapitellar and trochlear/ulnar joints are intact.\n\n IMPRESSION: No fracture or dislocation.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2188-02-08 00:00:00.000", "description": "ADD'L 2ND/3RD ORDER", "row_id": 782118, "text": " 11:15 AM\n SPINAL ART Clip # \n Reason: THORACIC SPINAL TUMOR, RENAL CELL CARCINOMA WITH METS TO T3 AND T4 VERTEBRAL BODIES\n Contrast: OPTIRAY Amt: 325\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL EMBO TRANSCRANIAL *\n * -59 DISTINCT PROCEDURAL SERVICE EMBO TRANSCRANIAL *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * TRANSCATH EMBO THERAPY TRANSCATH EMBO THERAPY *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * -59 DISTINCT PROCEDURAL SERVICE F/U TRANS CATH THERAPY *\n * F/U TRANS CATH THERAPY F/U TRANS CATH THERAPY *\n * F/U TRANS CATH THERAPY SPINAL SEL A-GRAM *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n ANESTHESIA: General endotracheal anesthesia in supine position.\n\n INDICATION: This is a patient who presents with metastatic disease to T3 and\n and T4 vertebral bodies and is undergoing a spinal angiogram for preoperative\n embolization of these lesions.\n\n CONSENT: The patient and his wife were given a full and complete explanation\n of the procedure. Specifically the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient and his wife understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood a 7 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n (Over)\n\n 11:15 AM\n SPINAL ART Clip # \n Reason: THORACIC SPINAL TUMOR, RENAL CELL CARCINOMA WITH METS TO T3 AND T4 VERTEBRAL BODIES\n Contrast: OPTIRAY Amt: 325\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n selectively catheterize the following vessels over a guidewire in succession:\n Right T3, right T4, right T5, right T6, left T3, left supreme, left T6, and\n left T5. At this point, examination of the various injections reveal the\n predominance of the supply to the tumors as emanating from right T3 and T4\n segmental arteries as well as the left T3 segmental artery. Accordingly, the\n patient was administered 2,000 units of heparin and a decision was made to\n proceed with transarterial embolization of the segmental arteries to the\n tumor. At this point, a microcatheter was used throughout a HS2 6.5 FR guide\n catheter and end succession the guide catheter was placed into the right T3\n segmental artery. With the guide catheter in this position, a microcatheter\n was used to selectively catheterize the various branches feeding the tumor to\n a total of four (3rd order) branches. After selection of each of these\n branches, a pre and post embolization run was performed and the branches were\n embolized using a combination using polyvinyl alcohol particles measuring 150\n to 250 microns in conjunction with fibered pushable coils. After the right T3\n contribution of the tumor was completely embolized to stasis, the guide\n catheter was placed into the right T4 and again two (3rd order) feeders to the\n tumor from the right T4 were embolized using particles and coils.\n Subsequently, the guide catheter was used to selectively catheterize the left\n T3 and the microcatheter was used through the left T3 to access two (3rd\n order) feeder arteries to the tumor. Accordingly, a total of three separate\n feeder segmental arteries mainly right T3 right T4 and left T3 were treated\n with particles and fibered pushable coils to preoperatively embolize the\n tumor.\n\n RESULTS: Injection these segmental arteries reveal normal anatomy except for\n the right T3, T4 and left T3 which provided significant blood supply to the\n tumors. These three branches in three separate fields were selectively\n catheterized and embolized using particles and pushable coils to stasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2188-02-07 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 1260408, "text": " 3:13 PM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: CORD COMPRESSION T4/T5 BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic lesions to the spine, further evaluation. Possible\n surgery.\n\n TECHNIQUE: CT of the T-spine with no IV contrast. 3D sagittal and coronal\n reconstructions were then performed.\n\n CT T-SPINE WITH NO IV CONTRAST: A large lytic lesion is noted in the T3\n vertebral body, extending to the right pedicle and transverse process. A\n large lytic lesion is also present, replacing almost the entire T4 vertebral\n body. A small anterior lytic lesion is present in T7.\n\n On the soft tissue windows, the T3 and T4 vertebral body lytic lesion is\n extending anteriorly to the paraspinal region, with associated prevertebral\n soft tissue mass. There also appears to be an epidural extension of this\n metastatic lesion with associated spinal cord compression. The small lytic\n lesion in the anterior T7 vertebral body also has broken through the anterior\n cortex into the prevertebral space.\n\n In the imaged portion of the lungs, innumerable nodules are demonstrated,\n consistent with extensive metastatic disease to the lungs. The hilar contours\n are prominent, which could represent hilar lymphadenopathy. In the imaged\n retroperitoneal soft tissue, both adrenal glands contain soft tissue masses,\n also highly suspicious for metastatic disease. A heterogeneous mass is noted\n in the imaged portion of the superior pole of the left kidney, probably\n representing the patient's renal cell carcinoma.\n\n The 3D reconstruction images are consistent with the above findings. A\n kyphotic deformity is present at the level of T3-4. T3 vertebral body is\n almost completely collapsed. T4 vertebral body is partially collapsed.\n\n IMPRESSION:\n\n 1) Lytic metastatic lesions to T3, T4 and T7 vertebral bodies. There is a\n kyphotic deformity at the T3-4 level. There is also extension of the tumor\n into the prevertebral and epidural space, causing spinal cord compression at\n T3-4 level. The T3 is almost completely collapsed. T4 is partially\n collapsed.\n 2) Extensive metastatic disease to the lungs.\n 3) Probable bilateral adrenal gland metastatic lesions.\n 4) Heterogeneous mass in the upper pole of the left kidney, likely\n representing the patient's known renal cell carcinoma.\n\n\n\n\n\n (Over)\n\n 3:13 PM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: CORD COMPRESSION T4/T5 BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2188-02-08 00:00:00.000", "description": "Report", "row_id": 1323576, "text": " NOTE\nPT ADMITTED FOR INTERVENTIONAL RADIOLOGY S/P SPINAL ANGIO. AND EMBOLIZATION. UPON ADMIT PT HYPOTHERMIC, TEMP 95.9 - BAIR HUGGER APPLIED. NBP 128 SYSTOLIC. RFEM SHEATH INTACT, SMALL AMT OF BLOODY OOZING NOTED. NO HEMATOMA. RGROIN SHEATH TRANSDUCED - ABP 178 - SICU TEAM NOTIFIED, NEUROSURG RESIDENT NOTIFIED, ORDERS TO GIVE 10MG IV HYDRALAZINE. PT ALERT AND ORIENTED X3 UPON ADMIT, PUPILS PINPOINT AND BRISKLY REACTIVE BILAT. PT ABLE TO MOVE UPPER EXT. W/ NL STRENGTH. LLE MOVES ON BED. RLE ABLE TO LIFT AND HOLD. LUNGS CTA BILAT. ABD SOFT. U/O QS VIA FOLEY. NS W/ 20MEQ KCL AT 100/HR.\nA/P: CONT CLOSE NEURO ASSESSMENT. MONITOR FOR S/S OF INFECTION. MONITOR FOR S/S OF BLEEDING. REPEAT ACT'S - PLAN FOR MD TO PULL GROIN SHEATH. CONT CURRENT TREATMENTS AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2188-02-09 00:00:00.000", "description": "Report", "row_id": 1323577, "text": "neuro status\nD: PT ALERT AND ORIENTED. FOLLOWS COMMANDS. MOVES LEFT LEG ON BED AND RT LEG LIFTS AND HOLDS. RT FEMORAL SHEATH REMOVED NO SIGN OF HEMATOMA OR BLEED ING GOOD CSM AND PULSES. C/O SHOULDER \"BURNINGLIKE A RASH WAS DEVELOPING\" NO RASH NOTED. RELIEVED WITH BACKRUB. AND SLIGHT REPOSITIONING. MEDICATED WITH MSCONTIN AS ORDERED. BS RE CLEAR ON R/A WITH O2 SAT OF 100%. URINE OUTPUT REMAINS ADEQUATE AND TOLERATING PO'S.\nA: CONTINUE WITH NERUO CHECKS THIS AM. ? TRANSFER OUT THIS AM.\nR: NEURO STATUS IS UNCHANGED. SHEATH SITE IS DRY AND INTACT. TOLERATING DIET WELL.\n" }, { "category": "ECG", "chartdate": "2188-02-10 00:00:00.000", "description": "Report", "row_id": 170679, "text": "Sinus arrhythmia\nLeft axis deviation consider left anterior fascicular block\nInferior ST-T changes may be due to myocardial ischemia\nNo previous tracing\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2171-10-24 00:00:00.000", "description": "Report", "row_id": 1424224, "text": "Condition Update\nPlease see carevue for specifics.\n\nPt arrived from the O.R. to the sicu approx 11:30am. Pt arrived via bed alert and oriented x3. Behavior appropriate. PERRL, c/o abdominal pain. Rating pain . morphine pca started. Minimal relief obtained. Morphine pca d/c'd dilauded pca started, toradol also given. Pt using pca appropriately. Good pain relief achieved w/ dilauded pca + toradol IV per pt. Also c/o nausea. Anzemt given. Nausea resolved post med. Pt moving all extremities with equal strength and to command. Low grade temps. sbp 170's. Lopressor ordered. LS are clear. Pt switched from face mask to own cpap machine d/t sleep apnea. c/o slight sob on RA. Pt remains NPO. LR infusing at 125cc hour. u/o adequate till approx 1700. 500cc LR bolus given. NGT to sxn and draining small amts of bilious fluid. Pt has RISS for bs coverage. Abdomen is soft + distended. Absent bowel sounds. Surgical dressing intact. Significant other at bedside.\n\nPlan: Continue with current plan of care per sicu team. closely monitor resp/ gu status. Pain mgmt. Monitor for s/s of infection.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-25 00:00:00.000", "description": "Report", "row_id": 1424225, "text": "Nursing note:\n A/Ox3, MAE. Dilaudid PCA w/good pain control. Lung sounds clear, encouraged to take deep breaths w/effect. SR in 80s-90s, no ectopy. SBP 130s-140s. Wearing pboots, sc heparin. Extremities slightly edematous. Sats 94-97%, wearing own BIPAP overnight for baseline sleep apnea. Does desat slightly to 88%-90% when given breaks from BIPAP by RT. Abdomen obese, soft. -BS or flatus. NPO. NGT to sxn for minimal bilious drainage. -Nausea. DSD intact to abdomen. Foley patent borderline amounts amber cloudy urine, bolused x2 overnight for low HUO w/some effect.\nA/P : Stable, good pain control. Continue current plan of care, monitor urine output, PCA, encourage pulm hygeine, BIPAP. ? Tx. to floor in am.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-26 00:00:00.000", "description": "Report", "row_id": 1424226, "text": "Update\nO: see carevue flowsheet for details.\nCv status: sr no ectopy sbp stable 120-150's w ivf at 125cc/hr.Distal pulses palp feet .\n\nResp status: attempted pt own bipap mask for overnight. Pt refusing to wear_>\" I feel like I can't breathe\". Pt removing mask and desats to 89-90 % on rm air->np at 3lpm w adeq abg.bbs clear dbc w/o raising sputum\n\nGi status: npo, no ng,no nausea. Mid abd drsg /d/i. PCA pump w dilaudid for pain w gd relief.Glucoses wnl no rx nec.+ bowel snds\n\nGu status: huo pale cl/y/u\n\nNeuro status: awake alert oriented x3 and weepy initially. Mid shift awoke frm sleep, picking at clothes. Pt following commands but slt confused-> reoriented to surroundings. Pt asking for S.O. and S.O. brought back to pt. .\n\nA/P: Stable ready to transf to floor w telemetry-> to floor when bed available.Check a.m labs and replete.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-26 00:00:00.000", "description": "Report", "row_id": 1424227, "text": "Update\nO: hemodynamics remains stable. CC6 private room available and pt ready to transfer to floor. Transf to cc611. Reported off to primary rn. .\n" } ]

[ { "category": "Echo", "chartdate": "2151-08-25 00:00:00.000", "description": "Report", "row_id": 100988, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain.\nHeight: (in) 60\nWeight (lb): 130\nBSA (m2): 1.56 m2\nBP (mm Hg): 128/56\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:36\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal/small IVC diameter (<=1.5cm) with\nrespiratory collapse (estimated RAP 0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 0-5mmHg. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%) Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\nascending aorta is mildly dilated. The aortic valve leaflets are moderately\nthickened. There is mild aortic valve stenosis (area 1.5 cm2). Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-08-21 00:00:00.000", "description": "Report", "row_id": 1666527, "text": "MICU NURSING PROGRESS NOTES :\nFULL CODE.\nALLERGY :NKDA\nPLEASE SEE CAREVUE FOR ADM HIST/ FHP AND OBJECTIVE DATA.\n\nNEURO : ALERT ,ORIENTED x , FOLLOWING COMMANDS MORE CONFUSED AS SHIFT PROGRESSED, REORIENTED TO PLACE AND TIME, BECAME MORE AGITATED AS WANTED TO GO TO THE BATHROOM EVEN THOUGH SHE HAS CATHETER IN PLACE.BILATERAL SOFT WRIST RESTRAINTS IN PLACE FOR SAFETY. COMPLAINS OF PAIN IN THE LEFT LEG, FAIR EFFECT WITH DILAUDID 2 MGS. PATIENT REQUESTED MEDICINE TO SLEEP, ATIVAN 1 MG IV GIVEN WITH NO EFFECT AND PO AMBIEN GIVEN WITH GOOD EFFECT. MOVEMENT RESTRICTED IN THE LLE, ABLE TO MOVE ALL OTHER EXTREMITIES, HAS 1 + EDEMA ON THE LLE, BILATERAL LL PULSES PALPABLE.\n\nRESP : REGULAR, UNLABOURED ,RR IN THE 20'S, SPO2 DECREASED TO THE LOW 90'S NC INITIATED AT 2 LITS WITH GOOD EFFECT. BILATERAL LUNG SOUNDS CLEAR.\n\nCVS : NSR WITH NO ECTOPY, NO COMPLAINS OF CHEST PAIN AT PRESENT, SBP 100's to 180's, MAP 50's to 90's. HCT DOWN TO 26.1, MD AWARE, NO PLAN TO TRANSFUSE AT PRESENT. FLUID BOLUS GIVEN FOR LOW URINE OUTPUT.\n\nGI: ABDOMEN IS SOFT, BS PRESENT, TOLERATING REG DIET. NO BM THIS SHIFT.\n\nGU : FOLEY CATH DRAINING MINIMAL YELLOW CLEAR URINE. PATIENT COMPLAINED OF NOT BEING ABLE TO PASS URINE AND FEELS LIKE SHE NEEDS TO PASS URINE. BLADDER NOT DISTENDED, CATHETER FLUSHED , NO OBSTRUCTION PRESENT. MONITORING CONTINUED FOR EFFECT OF THE FLUID BOLUS ON THE URINE OUTPUT.\n\nSKIN: INTACT, LT LEG ELEVATED ON THE PILLOW, WITH MINIMAL MOVEMENTS.\n\nSOCIAL : LIVES ALONE, HAS CAREGIVERS AT HOME, SON IS THE HEALTH PROXY. HE HAS REQUESTED TO REDO THE PAPERWORK AGAIN AS THE OFFICIAL PAPERS ARE LOST. THIS NEEDS TO BE DONE BEFORE TUESDAY AFTERNOON AS HE WILL BE OUT OF TOWN AFTER THAT.\n\nPLAN :\n TO CONTINUE SERIES OF HCT.\n PAIN MANAGEMENT.\n MONITOR CARDIO/ RESPIRATORY STATUS.\n MONITOR URINE OUTPUT.\n EMOTIONAL SUPPORT TO PATIENT.\n ORTHO CONSULT FOR OR/ TRACTION.\n" }, { "category": "Nursing/other", "chartdate": "2151-08-21 00:00:00.000", "description": "Report", "row_id": 1666528, "text": "0700-1900\nsee transfer note\n" }, { "category": "ECG", "chartdate": "2151-08-24 00:00:00.000", "description": "Report", "row_id": 294005, "text": "Supraventricular tachycardia which may be sinus with a P-R interval of 0.18.\nThere is ST-T segment depression in the posterolateral leads. These findings\nare new as compared with tracing of . Rule out active ischemic process.\nFollowup and clinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2151-08-20 00:00:00.000", "description": "Report", "row_id": 294006, "text": "Sinus bradycardia. Q-T interval prolongation. Probable prior inferior\nmyocardial infarction. Prior anteroseptal myocardial infarction cannot be\nexcluded. Compared to the prior tracing of no diagnostic interim\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-08-20 00:00:00.000", "description": "Report", "row_id": 294007, "text": "Sinus bradycardia. Q-T interval prolongation. Prior inferior myocardial\ninfarction. Compared to the prior tracing no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2151-08-24 00:00:00.000", "description": "Report", "row_id": 294004, "text": "Sinus rhythm with slowing of the rate as compared with tracing of .\nThe ischemic appearing ST segment changes have largely resolved. Followup and\nclinical correlation are suggested.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-06-21 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1193115, "text": " 10:18 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for infectious process, megacolon\n Admitting Diagnosis: UC FLARE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with UC flare, now with fever, rising CRP and ESR. PLEASE USE\n PO CONTRAST ONLY\n REASON FOR THIS EXAMINATION:\n eval for infectious process, megacolon\n CONTRAINDICATIONS for IV CONTRAST:\n allergy\n ______________________________________________________________________________\n WET READ: 11:17 PM\n Featurelss colon from mid-transverse colon to the rectum, with wall\n thickening, compatible with chronic inflammatory changes. No free air or\n pneumatosis. No bowel obstruction. No fat stranding to suggest more acute\n inflammation. No fluid collections.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: UC flare with fever and rising CRP and ESR.\n\n COMPARISON: CT chest , CT pelvis .\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness with oral contrast only.\n Coronal and sagittal reformats were displayed with 5-mm slice thickness.\n\n CT ABDOMEN: There is mild bibasilar dependent atelectasis. No pleural or\n pericardial effusion is seen. A small hiatal hernia is noted.\n\n Evaluation of the intra-abdominal organs is limited without intravenous\n contrast. Diffuse hypodensity of the liver is consistent with fatty\n deposition. Nodular increased density adjacent to the gallbladder fossa is due\n to focal sparing.\n\n The unenhanced spleen, pancreas and bilateral adrenal glands are normal.\n Multiple gallstones are seen within the gallbladder without pericholecystic\n fluid. The renal contours are symmetric without hydronephrosis.\n\n The small and large bowel are normal in course and caliber without\n obstruction. The colon is featureless from the mid transverse colon through\n the rectum with bowel wall thickening, suggestive of chronic inflammatory\n change. No adjacent fat stranding is seen to suggest acute inflammation.\n There is no free fluid and no free air. The aorta is of normal caliber\n throughout. No pathologically enlarged mesenteric or retroperitoneal lymph\n nodes are present.\n\n CT PELVIS: The rectum and sigmoid colon are decompressed with a slightly\n thickened wallm consistent with chronic inflammation. There is no fat\n stranding to suggest acute inflammation. The uterus and bladder are normal.\n Phleboliths are noted in the pelvis. There is no free fluid or pelvic or\n (Over)\n\n 10:18 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for infectious process, megacolon\n Admitting Diagnosis: UC FLARE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inguinal lymphadenopathy.\n\n BONE WINDOWS: No lytic or sclerotic lesion suspicious for malignancy is seen.\n A tiny sclerotic focus in the right sacral ala is unchanged from and\n is likely a bone island.\n\n IMPRESSION:\n 1. No acute process in the abdomen or pelvis to explain patient's symptoms.\n 2. Featureless colon from the transverse colon to the rectum with bowel wall\n thickening is compatible with chronic inflammatory change. No evidence of\n acute inflammation.\n 3. Fatty liver with focal sparing.\n 4. Cholelithiasis without evidence of acute cholecystitis.\n 5. Small hiatal hernia.\n\n" }, { "category": "Radiology", "chartdate": "2170-06-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1193117, "text": " 10:41 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna, infectious process\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with UC flare, fever to 100.4, sputum production\n REASON FOR THIS EXAMINATION:\n eval for pna, infectious process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n FINDINGS:\n\n In comparison with study of , there is continued mild low lung volumes\n with minimal atelectatic changes at the left base. No evidence of acute\n pneumonia or vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1194690, "text": " 3:08 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: l dl picc. ra. pull back. repeat x-ray\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with picc\n REASON FOR THIS EXAMINATION:\n l dl picc. ra. pull back. repeat x-ray\n ______________________________________________________________________________\n WET READ: NATg SUN 3:49 PM\n PICC remains 8.2cm from cavo-atrial junction, pull back additional 3cm (was\n only pulled back 1cm by report previously).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line after pull back.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n A left subclavian PICC line is present -- the tip overlies the right atrium,\n in the setting of low inspiratory volumes. Please see wet provided by\n radiology resident, Dr. , recommending pulling the PICC line back an\n additional 3 cm.\n\n Pulmonary parenchymal findings are unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2170-06-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1194475, "text": " 3:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Assess for CVL placement R IJ\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with sepsis and new CVL. PUlled back line.\n REASON FOR THIS EXAMINATION:\n Assess for CVL placement R IJ\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis and new CVL repositioned.\n\n COMPARISON: .\n\n FINDINGS: The patient is malpositioned with exclusion of the left lateral\n portion of the hemithorax. There may be mild right basilar atelectasis, but\n the visualized lung parenchyma is otherwise clear.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-01 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1194658, "text": " 9:55 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: interrogate dvt; please perform at bedside due to labile hem\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with h/o extensive LLE dvt and pe\n REASON FOR THIS EXAMINATION:\n interrogate dvt; please perform at bedside due to labile hemodynamics. thankyou\n ______________________________________________________________________________\n WET READ: KKgc SUN 10:46 PM\n 1. Occlusive DVT of the left popliteal vein and non-occlusive DVT of the left\n common femoral and proximal superficial femoral vein. Likely recanalization\n of the mid and distal superficial femoral vein.\n\n 2. No DVT in the right lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old woman with history of extensive left lower extremity\n DVT and pulmonary embolism, to assess DVT.\n\n COMPARISON: Bilateral lower extremity DVT study .\n\n FINDINGS: Grayscale and Doppler son of bilateral common femoral,\n superficial femoral and deep femoral were performed.\n\n RIGHT LOWER EXTREMITY VEINS: There is normal compressibility, flow and\n augmentation throughout. No DVT in the right lower extremity.\n\n LEFT LOWER EXTREMITY: There is a non-occlusive thrombus involving the left\n common femoral and proximal superficial femoral vein and an occlusive thrombus\n involving the left popliteal vein. Recanalization of the mid and distal\n portion of the left superficial femoral vein compared to the prior study. Flow\n is demonstrated within the proximal left calf veins.\n\n The above findings were discussed with Dr. immediately after the\n study.\n\n" }, { "category": "Radiology", "chartdate": "2170-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1194350, "text": " 9:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new/atypical pna\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Please disregard the previous report under this clip #. This is the\n correct report for this patient.\n\n HISTORY: Prednisone, to assess for pneumonia.\n\n FINDINGS: In comparison with the study of , there is little change and no\n evidence of acute pneumonia. Continued low lung volumes.\n\n The increasing prominence of the azygos region may well reflect the portable\n AP rather than upright PA technique.\n\n\n\n 9:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new/atypical pna\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with UC on high dose prednisone, new hypotension.\n REASON FOR THIS EXAMINATION:\n eval for new/atypical pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the nasogastric\n tube extends to about the level of the esophagogastric junction and should be\n pushed forward several centimeters. Otherwise, no change in the appearance of\n the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1194737, "text": " 3:45 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for PICC site placement\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with UC, cdiff, s/p PICC placement.\n REASON FOR THIS EXAMINATION:\n eval for PICC site placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with ulcerative colitis,\n Clostridium difficile, and PICC line placement.\n\n Portable AP radiograph of the chest was reviewed with comparison to obtained at 3:09 p.m.\n\n The right PICC line tip can be seen at least at the level of cavoatrial\n junction but potentially can be continuing inside the right atrium.\n Correlation with lateral view is recommended. To secure its position above\n the cavoatrial junction, it should be pulled back at least 2 cm with repeated\n radiograph evaluation.\n\n Left retrocardiac consolidation has increased in the interim consistent with\n atelectasis or infectious process. Patient continues to be in mild\n interstitial pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-06-28 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1194335, "text": " 7:15 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for bowel perforation, intraabdominal source of bleed.\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with ulcerative colitis, c. diff, acute drop in HCT\n (29->25->21)\n REASON FOR THIS EXAMINATION:\n eval for bowel perforation, intraabdominal source of bleed.\n CONTRAINDICATIONS for IV CONTRAST:\n severe allergy\n ______________________________________________________________________________\n WET READ: 8:55 PM\n No intraperitoneal or retroperitoneal hemmorrhage. Ahaustral, featureless\n colon in keeping with provided hx of UC. Equivocal superimposed wall\n thickening (ie rt colon) without adjacent inflammatory change - eval limited\n given lack of iv or po contrast. No free fluid or free air to suggest\n perforation. No intraabdominal abscess. Cholelithiasis without ct evidence\n of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ulcerative colitis and C. diff colitis with hematocrit drop.\n Evaluate for intra-abdominal source of bleed or bowel perforation.\n\n COMPARISON: CT scans and .\n\n TECHNIQUE: MDCT imaging was obtained through the abdomen and pelvis without\n intravenous or oral contrast. Coronal and sagittal reformations were\n evaluated.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS OR ORAL CONTRAST: 2-3 mm peripheral\n right middle lobe nodule is unchanged (2:3) when compared to the \n examination as is a similar sized left lower lobe peripheral nodule (2:11),\n possible punctate calcified granuloma is also noted within the right lower\n lobe (2:9). There is no pleural or pericardial effusion.\n\n There is unchanged cholelithiasis and hepatic steatosis with unenhanced images\n of the remaining intra-abdominal organs including the spleen, stomach, small\n bowel, pancreas, adrenal glands, and kidneys appearing unremarkable. No free\n air, free fluid, or pathologically enlarged lymph nodes are present. No\n retroperitoneal hemorrhage is noted.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS OR ORAL CONTRAST: Please note detail is\n slightly obscured due to beam-hardening artifact related to patient size.\n Within these limits no abnormalities involving the bladder, uterus, or adnexa\n are seen. Ahaustral appearance to the large bowel consistent with provided\n history of ulcerative colitis is again noted with no significant wall\n thickening identified and no distention to suggest toxic megacolon. Terminal\n ileum appears unremarkable with some fatty hypertrophy noted along the\n ileocecal valve. No free fluid or pathologically enlarged lymph nodes are\n identified.\n\n (Over)\n\n 7:15 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for bowel perforation, intraabdominal source of bleed.\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No findings of advanced sacroiliitis or aggressive osseous\n lesion.\n\n IMPRESSION:\n 1. No retroperitoneal hemorrhage or findings to explain hematocrit drop.\n\n 2. Little interval change to the appearance of large bowel which is\n predominantly ahaustral and consistent with the provided history of chronic\n ulcerative colitis. No definite findings of superimposed acute inflammation.\n\n 3. Unchanged cholelithiasis and hepatic steatosis.\n\n 4. Stable sub-4 mm pulmonary nodules. In a patient of this age without any\n risk factors for intrathoracic malignancy no further followup for these\n nodules is necessary Society guidelines.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1194682, "text": " 2:00 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 53cm left picc. tip?\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 53cm left picc. tip?\n ______________________________________________________________________________\n WET READ: NATg SUN 2:35 PM\n picc tip at least 9 cm from carina, rec pull back 4cm and repeat film.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line.\n CHEST, 1 VW\n\n The vascular markings appear prominent and there is apparent increased\n retrocardiac density. However, the significance of these findings is limited,\n given low inspiratory volumes.\n\n A left subclavian central line is present -- the tip overlies the right\n atrium. Please see wet report by radiology resident Dr. \n recommending pulling back the line by\n 4 cm. No pneumothorax is detected.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-02 00:00:00.000", "description": "INTERUP IVC", "row_id": 1194764, "text": " 8:58 AM\n IVC GRAM/FILTER Clip # \n Reason: please place IVC filter\n Admitting Diagnosis: UC FLARE\n Contrast: OPTIRAY Amt: 45\n ********************************* CPT Codes ********************************\n * INTERUP IVC PERC PLCMT IVC FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with hx of PE and current LLE DVT, UC with bleeding.\n REASON FOR THIS EXAMINATION:\n please place IVC filter\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 41-year-old woman with history of pulmonary embolism and\n recurrent left lower extremity DVT, for placement of IVC filter.\n\n CLINICIANS: Dr. , and Dr. .\n The attending, Dr. performed the procedure.\n\n Moderate conscious sedation was provided by administering 75 mcg of fentanyl\n and 1 mg of Versed throughout the total intraservice time of 50 minutes,\n during which the patient's hemodynamic parameters were continuously monitored\n by a trained radiological nurse. 1% buffered lidocaine was used at the right\n groin for local anesthesia.\n\n PROCEDURE AND FINDINGS: After explaining the risks and benefits of the\n procedure, written informed consent was obtained. The patient was brought to\n the angiography suite and placed supine on the imaging table. A preprocedure\n timeout and huddle was performed per protocol. The right groin was\n prepped and draped in usual sterile fashion for a percutaneous approach.\n\n Using fluoroscopic and continuous ultrasound guidance, the right common\n femoral vein was accessed using 19-gauge needle and wire was passed\n distally into the IVC. The needle was then exchanged for 5 French Omniflush\n catheter, which was placed at the region of the IVC confluence and cavogram\n was performed which demonstrated a patent and good caliber IVC. There was no\n reflux filling seen in the left iliac vein. The proximal right common iliac\n vein appears patent and is of normal caliber. The level of the lowest renal\n vein was marked using the radiopaque marker. The wire was\n reintroduced into the IVC through the indwelling Omniflush catheter, and\n attempts were made to retrogradely catheterize the left common iliac vein,\n which proved unsuccessful. The catheter was exchanged for a 6 French sheath of\n Option IVC filter. Option IVC filter was then deployed below the level of the\n left renal vein . Since the left iliac vein was not demonstrable on the\n cavogram, we decided to access the left common femoral vein using ultrasound\n guidance and micropuncture needle. The guide was advanced into the left\n common iliac vein and the needle exchange for a micropuncture sheath. A\n venogram was peformed with hand injection, which showed an attenuted left\n iliac vein, likely secondary to chronic thrombosis or hypoplasia. No\n demonstrable collateral veins are seen.At the end of the procedure, the\n sheaths were removed bilaterally and compression was held on bilateral groins\n (Over)\n\n 8:58 AM\n IVC GRAM/FILTER Clip # \n Reason: please place IVC filter\n Admitting Diagnosis: UC FLARE\n Contrast: OPTIRAY Amt: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n until complete hemostasis was achieved. The patient withstood the procedure\n well and had no immediate complications and was shifted back to the floor in\n stable condition. Final spot fluoroscopic image demonstrated good position of\n the Option filter with no evidence of tilt or migration.\n\n IMPRESSION:\n\n 1. Uncomplicated placement of a retrievable Option IVC filter in the\n infrarenal IVC location.\n\n 2. Venogram performed through the left iliac vein demonstrating attenuated\n left iliac vein likely secondary to chronic thrombosis or hypoplasia.\n\n" }, { "category": "Radiology", "chartdate": "2170-07-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1195819, "text": " 9:39 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p colectomy\n Admitting Diagnosis: UC FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with UC now s/p colectomy\n REASON FOR THIS EXAMINATION:\n s/p colectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post colectomy for ulcerative colitis.\n\n COMPARISON: CT ; multiple radiographs dating back to , most\n recently .\n\n FINDINGS: Low lung volumes result in bronchovascular crowding. The right\n PICC tip ends in the mid SVC. Pulmonary edema and atelectasis have\n significantly improved since with mild residual bibasilar\n atelectasis and perihilar pulmonary vascular engorgement. No pneumothorax.\n Small left pleural effusion. Cardiac and mediastinal silhouettes are normal.\n\n" }, { "category": "ECG", "chartdate": "2170-07-10 00:00:00.000", "description": "Report", "row_id": 307854, "text": "Sinus tachycardia. RSR' pattern in leads V1-V2. Since the previous tracing\nof the rate is faster. RSR' pattern in leads V1-V2 is new and axis is\nmore leftward. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2170-07-06 00:00:00.000", "description": "Report", "row_id": 307855, "text": "Sinus bradycardia. Otherwise, normal tracing. Compared to the previous\ntracing of the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2170-06-28 00:00:00.000", "description": "Report", "row_id": 307856, "text": "Sinus rhythm. Modest diffuse ST-T wave changes which are non-specific.\nCompared to the previous tracing of there is no significant diagnostic\nchange.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2189-03-07 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 956932, "text": " 10:30 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: EVALUATE LUNG FIELDS\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RESPIRATORY DISTRESS, BORN AT TERM BY C-SECTION\n REASON FOR THIS EXAMINATION:\n EVALUATE LUNG FIELDS\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 22:36 HOURS.\n\n HISTORY: Newborn with respiratory distress, status post C-section at full\n term.\n\n Supine view of the chest obtained portably demonstrates patchy/streaky\n opacities at the lung bases associated with hyperinflated lungs and suggestion\n of a small amount of pleural fluid that blunts the right costophrenic angle.\n Findings are most consistent with TTN but neonatal pneumonia remains a\n possibility. Further followup would be helpful. The heart appears mildly\n enlarged in size with normal pulmonary blood flow. Visualized osseous\n structures are unremarkable.\n\n IMPRESSION: Findings consistent with TTN versus neonatal pneumonia. Further\n followup would be helpful.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-03-12 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 957523, "text": " 1:15 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: resp distress and o2 requirement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with oxygen requirement, R/O pneumonia\n REASON FOR THIS EXAMINATION:\n resp distress and o2 requirement\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM DATED, at 13:33.\n\n CLINICAL HISTORY: Concern for right lower lobe pneumonia.\n\n Compared to , the right lower lobe opacity is now milder but it is still\n present. Findings still may be consistent with right lower lobe pneumonia.\n The left lung remains clear. The cardiac silhouette is slightly accentuated\n by the fact that the thymus appears relatively small. Pulmonary vasculature\n is normal.\n\n" }, { "category": "Radiology", "chartdate": "2189-03-09 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 957088, "text": " 11:56 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with TTN vs pneumonia FT\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n Infant with pneumonia or transient tachypnea of the newborn. Comparison is\n done to the study two days ago. The heart is in the upper limits of normal\n with an uplifted cardiac apex. The mediastinum is narrow. There are diffuse\n opacities throughout the lungs. There are also more focal airspace\n opacities in the right and left lung bases concerning for pneumonia. There is\n no associated pleural effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-13 00:00:00.000", "description": "Report", "row_id": 2020619, "text": "Nursing Progress Note:\nI have assessed this infant and agree w/ the above note by PCA . Infant now day day course IV ampicillin and gentamycin. PIV in L arm intact. Flushed w/ heparin @ 1200, 1800. Infant stable in RA. No drifting, spells. Infant waking q 2-3hrs, primarily breastfeedings during the day. Breastfed for 30min x2 thus far this shift. Well coordinated w/ strong suck. Discharge teaching done at bedside by this RN. VNA contact. pedi RN's at either agency to see infant. paged.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-13 00:00:00.000", "description": "Report", "row_id": 2020620, "text": "Neonatology NNP note\nPE:\n\nNEURO: infant swaddled in open crib, active on exam, AFOS, sutures sl overlap, MAE x4.\n\nRESP: infant in r/a, breath sounds = clear with no retractions.\n\nCARDIAC: color pink well perfused, no audible murmur on exam, pulses palpable =x4, cap refill < 3secs, mucuos membranes pink and moist.\n\nSKIN: intact, no lesions, rashes or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal male genitalia, penis redden and swollen from circumzision.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-14 00:00:00.000", "description": "Report", "row_id": 2020621, "text": "Nursing Progress Note:\n\nID:\nO: Today day 7 of 7 of Ampi and Gent. Blood cultures\nnegative to date. VS stable.\nA: Stable infant.\nP: Complete course of abx today.\n\nRESP:\nO: Infant remains in RA. RR 30-60's with sats remaining\n>94%. LS clear and equal. No retractions or increased WOB\nnoted. No a/b spells or desats.\nA: Stable in RA\nP: Cont to monitor\n\nFEN:\nO: Wt 4075, down 70g. Infant ad-lib feeding BM/ 20.\nInfant waking every 2-3.5 hours. At 1900 infant took 45cc\nby bottle. At 2230 infant BF well for 30min. At 2400 infant\ntook 90cc by bottle. Infant is well coordinated and is eager\nto eat. Abdomen soft, round, +BS. No spits. Infant voiding\nand stooling. Circ site healing well. Vaseline gauze\napplied. Please see flowsheet for details.\nA: Tolerating feeds well.\nP: Cont to ad-lib feed infant.\n\nDEV:\nO: Temps stable; infant swaddled in an OAC. Font s/f. Infant\na/a with cares; waking for all feeds. Tone within normal\nlimits; MAE. Infant brings hands to face. Enjoys his\npacifier. Sleeps well between cares. Carseat test done-\ninfant passed. Hearing screen to be done prior to d/c. VNA\nto be contact in AM. Pedi appt scheduled for Monday .\nA: AGA\nP: Planning for D/C home today.\n\nSOC:\nO: visited at bedside until 2300. Updated regarding\nand status and plans for d/c. independent with\ncares. Mom BF infant well, and dad bottled infant well. Mom\ncont to pump. planning to return in AM. \nstate they feel prepared for infant's d/c\nA: Bonding well with infant\nP: Cont to support, educate and keep informed. Complete d/c\nteaching in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-13 00:00:00.000", "description": "Report", "row_id": 2020616, "text": "Nursing Progress Note:\n\nID:\nO: Infant remains on ampi and gent for 7 day course. Blood\ncultures negative to date. VS stable.\nA: Stable infant.\nP: Cont abx and monitor for s/sx's of infection.\n\nRESP:\nO: Infant remains in RA this shift. RR 40-60's with sats\nremaining >96%. No retractions or increased WOB noted. LS\nclear and equal. No a/b spells or desats noted.\nA: Stable in RA.\nP: Cont to monitor closely.\n\nFEN:\nO: Wt 4145g, no change. Infant ad-lib feeding BM/ 20.\nInfant waking every 4 hours thus far. At , infant BF\nwell for 35min. At 0030 infant took 120cc by bottle. Infant\nis well coordinated while bottling, using a yellow nipple.\nTotal 24hr intake= 40cc/kg + BF well x5. Abdomen soft,\nround, +BS. No spits noted. Infant voiding and stooling.\nCirc site remains clean and dry, vaseline gauze applied-\nplease see flowsheet for details.\nA: Tolerating feeds well\nP: Cont infant on ad-lib demand schedule.\n\nDEV:\nO: Temps stable; infant swaddled in an OAC. Font s/f. Infant\na/a with cares; waking for all feeds. Tone within normal\nlimits; MAE. Infant reaches hands to face and enjoys his\npacifier. Sleeps well between cares.\nA: AGA\nP: cont to support development.\n\nSOC:\nO: in for cares. Updated regarding infant's\nstatus and plan of care. Mom BF infant and also cont to\npump. plannning to visit today, and will call in am\nfor update.\nA: Bonding well with infant.\nP: cont to support, educate and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-13 00:00:00.000", "description": "Report", "row_id": 2020617, "text": "Neonatology Attending Progress Note\n\nNow day of life 6, CA 1/7 weeks.\nIn RA since :00 yesterday with\nRR 40-60s O2 saturation >96%\nHR 120-160s BP 75/42 54\n\nWt. 4145gm - no change\nFeedings continue to go well with breast and bottle feedings of MM.\nNormal urine and stool output.\n\nFU CXR improved.\n\nID - on day 6 of antibiotics for presumed pneumonia.\n\nAssessment/plan:\nVery nice progress with normal O2 saturation on RA.\nWill be able to go home tomorrow afternoon if continues to do well.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-13 00:00:00.000", "description": "Report", "row_id": 2020618, "text": "PCA Progress Note \n\n\n#1 SEPSIS: Infant remains on 7 day course of ampi and gent.\nVS stable. Continue to monitor.\n\n#2 RESP: Infant in room air breathing 30-60s with O2 sats\n>93%. LS clear/equal, no increased WOB. Breathing\ncomfortably in room air. Continue to monitor respiratory\nstatus.\n\n#3 FEN: Ad lib demand infant waking q3-4hrs and taking\nadequate amounts of BM/SIM20. Breast feeds well with mom\nand is coordinated bottling using yellow nipple. All PG.\nAbd benign, no loops, +BS. Voiding and stooling (stool not\ntested d/t blood on gauze from circ). Tolerating feeds.\nContinue to follow nutritional plan.\n\n#4 SOC: Mom and dad in throughout afternoon with guests.\nUpdated at bedside by RN and reviewed some discharge\nteaching. Asking appropriate questions. Loving family,\ncontinue to update and support.\n\n#5 DEV: Temps stable swaddled in OAC. Alert and active with\ncares, resting well in between. MAE. AFSF. Brings hands to\nface, enjoys pacifier. Has PIV in right arm. Circ site\nslightly red, healing well. Vaseline gauze applied. AGA.\ncontinue to support developmental needs.\n\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-10 00:00:00.000", "description": "Report", "row_id": 2020601, "text": "Neonatology Attending Progress Note\nNow day of life 3, CA 5/7 weeks.\nOn supplemental O2 - 13cc of 100%.\nRR 20-60s HR 120-140s BP 72/47 54\nNo apnea/bradycardia.\n\nCXR - noted to have opacities consistent with pneumonia\n\nWt. 4280gm down 100gm on ad lib feedings\nBaby is breastfeeding and bottle feeding.\nOff IV therapy for a full day.\nDS 68-80\n\nID - on amp and gent\n\nBili 8.5\n\nAssessment/plan:\nTerm LGA infant with clinical picture consistent with pneumonia.\nWill plan on at least 7 day course of antibiotics.\nFamily meeting tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-10 00:00:00.000", "description": "Report", "row_id": 2020602, "text": "NP NOTE\nPE: large term infant swaddled in open crib., PInk, well erofused on nasal caula O2, mildly jaundiced.\nAFOF sutures approximated, eyes clear, nraes intact, MMMP\nChest is symmetric with slightly diminished bs in basesR>L, fair exchgane.\nCV: RRR, no murmur , pulses+2=\nAbd: soft with active bs, cord dry\nGU: testes in scrotum\nEXT: well developed, MAE PIV in palce.\nNeuro: actiev with good tone, symmetric refelxes.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-10 00:00:00.000", "description": "Report", "row_id": 2020603, "text": "Nursing Progress Note 0700-1900\n\n\nSEPSIS O/A: Infant continues on day of IV Abx of Ampi &\nGent. No overt s/s of sepsis noted today. P: Cont current rx\n& monitor.\n\nRESP O/A: Infant maintaining O2 sats >94% in a NC 100% FiO2\n, 13-25cc flow. RR 40-60s, LS clear/=, sc rtxns. P: Cont to\nmonitor need for cannula.\n\nFEN O/A: Ad lib breastfeeding & bottling Sim20. Inconsistant\nwith breast & bottle feeds. Occasionally drowsy. D-sticks\n69/64/78 today. Infant needs to be woke for q3h feedings.\nAbdomen soft/round, active BS. Dry diaper x2, large void\nnoted @ 1730, mec stool x1. P: Cont to encourage po intake.\nMonitor d-sticks.\n\nPAR O/A: & grandparents visiting throughout the day.\nUpdated at the bedside by this RN & MD . \ngaining independence with temps, diaper changes and\nfeedings. P: Cont to encourage family.\n\nG&D O/A: Swaddled in an OAC; temps stable. MAE, AFSF, likes\npacifier. Not waking consisitantly for feeds. P: Cont to\nsupport developmental needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020604, "text": "NPN NIGHTS\n\n\nPOT FOR SEPSIS:REMAINS ON AMPI AND GENT DAY 4 OF 7 NOW. NO\nTEMP INSTABILITY, NO S/S OF INFECTION. PRE GENT TONIGHT 0.3,\nPOST GENT PENDING. CONTINUE OT MONITOR FOR S/S OF INFECTION.\n\n\nALT IN RESP:REMAINS IN NASAL CANNULA, 100%, 25CC MOSTLY\nTONIGHT. LUNGS CLEAR, RR 60'S WTIH MILD SUBCOASTAL\nRETRACTIONS. NO EPISODES OF APNEA OR BRADYCARDIA THIS SHIFT.\n CONTINUE TO MONITOR RESP STATUS CLOSELY AND WEAN O2 AS TOL.\n\n\nALT IN NUTRITION R/ :AD LIB DEMAND FEEDS, OF BM OR \n20. ABD EXAM BENIGN. NO LOOPS, NO SPITS. VOIDING WITH EVERY\nDIAPER CHANGE. 1 SMALL MEC STOOL. D/S 87 TONIGHT. WGT DOWN\n95 TO 4185 TONIGHT. BOTTLING Q3-4HRS. BF WELL WITH MOM AT\n9PM, AND THEN BOTTED 30CC. NEXT FEEDING BOTTLED 40CC. MOM IS\nSLEEPING THROUGH THE NIGHT. CONTINUE CURRENT FEEDING PLAN.\nFEED Q3-4HRS.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS ON AND OFF BTW FEEDS. IRRITBALE AT TIMES.\nSUCKS ON PACIFER BRIEFLY. CONTINUE DEVELOPMENTAL CARES.\n\nALT IN PARENTING: UP TO VISIT TWICE THIS EVE. UPDATED\nAT BEDSIDE. MOM BF AND THEN BOTTLED BABY AND HELD HIM FOR A\nWHILE. THEY ARE INDEPENDENT WITH FEEDINGS. CONTINUE TO\nSUPPORT AND UPDATE.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-09 00:00:00.000", "description": "Report", "row_id": 2020599, "text": "0700- NPN\n\n\nID: Continues on Ampicillin and Gentamicin, treatment for\nr/o pneumonia. Plan to continue antibiotics at least through\ntomorrow M.D. Chest x-ray done today is improved from\nyesterday but M.D. still unable to rule out pneumonia vs.\nTTN or RDS.\n\nRESP: Infant was placed in a nasal cannula this afternoon in\norder to keep sats >94% per order. He is currently in a\nlow-flow meter nasal cannula at 25cc flow/100% fi02. Will\nwean as tolerated. RR 30s-70s, mild-moderate SC retractions\npresent. Lung sounds clear and equal. X-ray done today (see\nID note above).\n\nFEN: Received on TF 50cc/kg/d D10w infusing via PIV. IVFs\nwere increased back up to 60cc/kg/d at 1000 after a dstick\nof 49. Infant bottled 55cc of Sim20 at that time. Follow-up\ndstick 3 hours later, 56. Infant bottled 25cc of Sim20 at\nthat time. Plan to keep infant on a q3hr po feeding schedule\nand wean IVFs as tolerated. Mom attempted BF infant but he\nwas sleepy at the time and did not latch. No spits, min asp.\nAbdomen soft, full, no loops, active BS. Voiding and mec\nstooling.\n\nPARENTING: Parents were in at 1300 to visit. Mom held and\nfed infant at that time. Parents were updated and asking\nappropriate questions. Mom has a lactation appointment for\nthis Wednesday. They plan to be in again for infant's next\nfeeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-10 00:00:00.000", "description": "Report", "row_id": 2020600, "text": "NPN Noc\n\n5 Alt in G&D\n\n#1 ID: Temp stable in OAC, infant is alert and active. Cont\nAmp and Gent, bld cxs NTD. P: Cont abx as ordered, monitor\nfor sx of sepsis.\n#2 Resp: NC 100% 13-25cc. Infant off NC for a few hours in\nthe eve, however bgan to drifts sats to low 90's. 20-60's,\nc/=, mild SC retrac. No spells. P: cont to monitor resp\nstatus, cont NC as needed for sats > 94%.\n#3 FEN: Infant ad lib Q3H feeding, taking about 40-45cc per\nfeed, breastfed x1 for about 5mins. IVF d10 at 15cc/kg\ncurrently, weaning with each feed, according to D sticks.\nDsticks 78 & 80 so far this shift. Abd benign, V/S, mec\nstooling. P: Cont to monitor FEN status, will turn off IVF\nand HL PIV this AM if D stick is acceptable.\n#4 : and grandmother in for 9pm cares, mom\nbreastfed, dad . appear very lovign towards\ninfant, asking appropriate questions. Mom will sleep o/n,\nwants to be called for 9am feeding. P: Cont to encourage\nparental calls and visits.\n#5 G&D: Temp stable in OAC, swaddled. Alert and active with\ncares, sleeps well in between. Enjoys his pacifier, MAE. PKU\nconsent obtained, will send state screen this AM. P: Cont to\nmonitor and suport G&D.\nSee flowsheet for further details\n\nREVISIONS TO PATHWAY:\n\n 5 Alt in G&D; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-14 00:00:00.000", "description": "Report", "row_id": 2020622, "text": "NP NOTE\nPE: large well appearing term infant swaddled in open ccrib. PInk, well perfused in RA. Quiet alert, awakens easily. AFOF sutures approximated, eyes clear, PERRL, red reflexe present bilaterally, nares patent, intact palate, MMMP\nNeck is supple, no masses, clavicles intact\nChest i s symmetric with clear, equal bs, comfortbale\nCV: RRR, no murmur, S1, splitS2 present, pulses=2=\nAbd: soft, round active bs, no HSm, cord dry\nGU: circumcied penis, healing, patent anus\nSpine is straight, smooth\nHips are stable, no clicks\nEXT: well developed, MAE PIV in place.\nNeuro: active with good tone, symmetric primitive relfexes.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-14 00:00:00.000", "description": "Report", "row_id": 2020623, "text": "Neonatology Attending Progress Note\n\nNow day of life 7, CA 2/7 weeks.\nIn RA with RR 30-60s\nStable cardiorespiratory status.\nHR 120-150s BP 75/42 54\n\nWt. 4075gm down 70gm on ad lib feedings of MM or Sim20\nBreastfeding is going very well.\nNormal urine and stool output.\n\nID - completing 7 day course\nCirc - healing well.\n\nPassed hearing screen and car seat testing.\n\nAssessment/plan:\nSteady progress continues.\nWill be ready for discharge to home later today.\nFU appointment with pediatrician set for Monday.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-14 00:00:00.000", "description": "Report", "row_id": 2020624, "text": "Nursing Discharge Note:\n\n1 Infant with Potential Sepsis\n2 Term Respiratory Distress\n3 Alteration in FEN\n4 Impaired parenting\n5 Alt in G&D\n\nInfant completed 7 day course of ampicillin and gentamycin\nthis afternoon @ 1200. Infant w/out overt s/sx of infection.\nIssue resolved. Infant breathing comfortably in RA. O2 sats\n>94% w/out drifting. Lung sounds cl/=. No retractions noted.\nNo episodes of apnea or bradycardia. Current weight =\n4.075kg (-70g). Infant ad lib demand breastfeeding/PO \n20. Waking for feedings q 3-4hrs, breastfeeds for about\n30min per feeding. Well coordinated w/ strong suck. Abdomen\nis benign. Infant voiding, stooling well. No spits. Circ\nsite healing. Covered w/ vaseline gauze. \ndemonstrated competency in circ care. Infant maintaing\nstable temps in OAC. Wakes for feedings. A/A throughout\ncares. MAE. AFSF. Heb B given. Bath done w/ . Infant\npassed both hearing and carseat tests. Pedi apt. made for\nMonday. Discharge teaching done at bedside by this RN. PKU\nsent today. Infant placed in carseat and safely discharged\nhome per team orders.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n 2 Term Respiratory Distress; resolved\n 3 Alteration in FEN; resolved\n 4 Impaired parenting; resolved\n 5 Alt in G&D; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-09 00:00:00.000", "description": "Report", "row_id": 2020596, "text": "NPN 7p-7a\n\n\n#1 Temps stable. On ampi and gent. Active. Blood cx NGTD. A:\nresp sx resolving P: Abx as ordered, follow exam\n\n#2 Remains in RA. Sats mx'd > 94%. BBS clear and =. Grunting\nessentially resolved. Mild SCR persist. Mild transient\ntachypnea evident. A: resp status improved P: Monitor resp\nstatus\n\n#3 Tf's 60cc/k. IVF of D10W infusing via PIV without\ndifficulty. DS 62. Abdominal exam unremarkable. Breast\noffered with fair interest, no latch. Po attempt offered\nafter seen by NNP . Took 20cc Sim20 with ease. Wet\ndiapers, passing med-lg meconium. Scrotum with hydroceles.\nA: beginning to po feed P: Support nutritional needs as exam\nallows, follow ds\n\n#4 Mom and Dad in x several. Mom stated she feels as though\nshe is having difficulty bonding d/t nicu stay for son.\nEmotional support offered. Involved dad with diaper changing\nand swaddling. Mom offered breast briefly x several. Each\nheld son for extended period. Pictures taken of son and\ngiven to mom to take downstairs. Would like to see an LC. A;\nvery pleasant family learning about newborn son P: Cont to\nsupport and inform\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-09 00:00:00.000", "description": "Report", "row_id": 2020597, "text": "Neonatology Attending Note\nDay 2, 38 4\n\nRA. RR60-80s. Cl and =. No murmur. HR 130-140s. BP 69/46, 54.\nWt 4380, down 135. TF 60 IVF + po ad lib. Nl voiding and stooling. Off warmer.\n\nA/P:\nGood respiratory progress. CXR with TTN versus neonatal pneumonia. Clinical course c/w TTN but given initial appearance of CXR will obtain another CXR to determine diagnosis and medical plan (course of abx). Cont to wean IVFs as po feedings increase.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-09 00:00:00.000", "description": "Report", "row_id": 2020598, "text": "Neonatology NNP note\nPE:\n\nNEURO: infant swaddled in open warmer, active on exam, AFOS, suture sl overlap, MAE x4.\n\nRESP: infant in r/a, breath sounds = clear with mild subcostal retractions.\n\nCARDIAC: color pink/sl jaundice well perfused, no audible murmur on exam, pulses palpable = x4, cap refill < 3secs, mucous membranes pink and moist.\n\nSKIN: intact, no lesions, rashes or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal male genitalia, bilateral hydroceles on exam, right scrotum with sl blue hue on exam.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-08 00:00:00.000", "description": "Report", "row_id": 2020590, "text": "Admission Note\nNICU Admit note:\n\nPls see previous note by Dr. describing mom's history and infants DR . Upon arrival to NICU infant placed on warmer. VSS. Persistent GFR evident. LS clear and =. O2 sats 87% in RA. ^ 97-98% with 100% BBO2. Placed in NC-started at 1/2 liter. ^ liter. Able to wean NC as noc progressed and when repositioning infants NC, RA challenge offered. Well saturated ~ 90mins but then began drifting to 91% immediately after being bundled,which did not resolve. NC O2 replaced at 100-150cc. Grunting now intermittent and flaring resolved. Sats mx'd > 94%. Chest x-ray with hazy bases. Soft murmur heard. CBC and blood cx sent. Diff unshifted. Initial doses of ampi and gent given. Remains NPO with D10W infusing at 60cc/k without incident. DS stable despite macrosomia. Has passed 39cc and a small mec. R scrotum with bluish circle. Hydrocele MD. Dad in to visit x several. Mom to floor d/t not feeling well. Took personal photos. Baby meds given. Becoming more fiesty. Vigorous with binkie. Swaddled on off warmer d/t warm.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-08 00:00:00.000", "description": "Report", "row_id": 2020591, "text": "NURSING PROGRESS NOTE\n\n\n1 = POT SEPSIS - PT ALERT W/ CARES. TEMP STABLE. ON AMP\nAND GENT. BLOOD CX PENDING\n\n2 - RESP - PT AT RA. BSC/=, MILD SC RETRACTIONS.\nINTERMITTENT GRUNTING. SAT>94%. NO DESATS, NO A/BS NOTED\n\n3 - FEN - TF=60CC/K OF D10W - INFUSING VIA PIV WITHOUT\nDIFFICULTY. ATTEMPTING TO BREAST FEED - NOT LATCHING, NOT\nSHOWING INTEREST AT THIS TIME. ABD SOFT, +BS. PT ,\nMEC STOOLS.\n\n4 - PARENT - MOM AND DAD IN TO VCISIT. HOLDING BABY. ASKING\n QUESTIONS, UPDATED AT BEDSIDE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-08 00:00:00.000", "description": "Report", "row_id": 2020592, "text": "NURSING PROGRESS NOTE\naddendum\n\nFEN - dstick at 1630 - 39 - ivf increased back to 60cc/k, follow dstick asfter 1 hr = 35. D10w bolus given at 1815. follow up dstick pending.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-08 00:00:00.000", "description": "Report", "row_id": 2020593, "text": "NURSING PROGRESS NOTE\naddendum\n\nFEN - dstick at 1630 - 39 - ivf increased back to 60cc/k, follow dstick asfter 1 hr = 35. D10w bolus given at 1815. follow up dstick pending.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-08 00:00:00.000", "description": "Report", "row_id": 2020594, "text": "Neonatology Attending Note\nDOL# 1, CGA 38 wk\n\nOn RA since earlier this morning\nStill with intermittent grunting\nGood sats\n\nP 130-140s\nPink\nMBP 52\n\nWt 4515 gm\nTF 60 cc/kg IVF\nD-sticks stable in the 60s\n\nVoiding and stooling\n\nOn Amp and Gent\n\n\nA/P:\nNewborn infant with TTN vs pneumonia.\nRESP: Now on RA. Continue to monitor resp status closely.\nCV: Stable BPs.\nFEN: Allow to trial BF and start feeds when resp status stabilizes. Wean IVF.\nID: Continue on antibiotics. If his status improves rapidly consider 48 hr course vs full 7 day course - follow cultures.\nSOC: Parents updated on the plan.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-08 00:00:00.000", "description": "Report", "row_id": 2020595, "text": "Neonatology NNP note\nPE:\n\nNEURO: infant swaddled on off warmer, active on exam, AFOS, sutures sl overlap, aga tone.\n\nRESP: infant in r/a, breath sounds = clear with mild subcostal retractions.\n\nCARDIAC: color pink well perfused, no audible murmur on exam, pulses palpable =x4, cap refill < 3secs, mucous membranes pink and moist.\n\nSKIN: intact, no lesions, rashes or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal male genitalia, bilateral hydroceles on exam. right scrotum sl blue hue on exam.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-07 00:00:00.000", "description": "Report", "row_id": 2020589, "text": "Admission Note\nNeonatology H&P\n\nBaby is a newborn LGA infant referred by Dr. for evaluation of hypoglycemia and respiratory distress.\n\nHe was born at 6:05 pm this evening as the 4515 gram product of a 38 wk gestation pregnancy to a 33 y.o. G1 P0-1 mother with . Prenatal labs included BT O+/Ab-, HBsAg-, RPR NR, RI, and GBS-. Pregnancy was notable for macrosomia, with no evidence of gestational diabetes. Over past few days, mother experienced mild hypertension and occasional headaches, eventually prompting c-section delivery today. Membranes were intact at time of delivery and there was no labor. Mother did not receive intrapartum antibiotics, and there were no sepsis risk factors noted.\n\nAt delivery, infant emerged vigorous with Apgars . Mild grunting was noted in L&D, but infant remained pink in RA. Dstik at 1 hour of age was 63, but dstik at 2 hours of age was 30, prompting referral to NICU.\n\nPhysical Exam:\nWt: 4515 gm.\nVS: T 99.1, HR 130s, RR 40-60s, BP 74/29 (45).\nO2sat 87%/RA, 97-98% with blow-by O2.\nGen: LGA infant, active with exam, mild work of breathing at rest.\nSkin: warm, pink, no rash.\nHEENT: fontanelles soft and flat, palate intact, ears/nares normal.\nNeck: supple, no lesions.\nChest: moderately aerated, clear, mild retractions, mild grunting.\nCardiac: RRR, no m.\nAbdomen: soft, full, quiet BS, no mass, no HSM.\nGU: normal male, testes descended, hydrocele in scrotum with small area of bluish discoloration distinct from testicle, anus patent.\nExt: hips/back normal, femoral pulses 2+.\nNeuro: appropriate tone, activity, poor suck.\n\nDstik: 63.\n\nIMP: Newborn LGA 38+ wk infant with mild respiratory distress and hypoglycemia. Respiratory distress is likely secondary to TTN. Hypoglycemia is likely related to LGA status, and has improved without intervention.\n\nPLANS:\n- Triage in NICU.\n- Monitor resp status, blow-by oxygen as needed.\n- If work of breathing or oxygen requirement persists, consider further evaluation including CBC/cx, CXR, blood gas.\n- Monitor dstiks.\n- Will need to consider IVF if respiratory distress persists or hypoglycemia recurs.\n- Will need to consider empiric abx if respiratory distress persists.\n- If symptoms improve and infant able to feed, can transfer to regular nursery.\n\nPMD: Dr. ().\nFather updated at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-12 00:00:00.000", "description": "Report", "row_id": 2020614, "text": "NPN 0700-1900\n\n#1 Sepsis\nO: Day IV Ampicillin and Gentamycin. Alert and acting well. Temp and VS are stable and WNL. Weaning 02 need.\nA: No s/s sepsis at present\nP: Continue IV antibiotics as ordered. Close observation and monitoring.\n\n#2 Alt. in Resp. Function\nO: Received infant in NC 02, 13cc 100%. Sats 96-100. Breath sounds are clear and =. Mild SC retractions continue. RR 40's-70's. No spells. CXR taken. Placed in RA at 1700. Sats remain >94.\nA: Doing well in RA thus far\nP: Continue close observation and monitoring. Document any spells or desats.\n\n#3 Alt. in Nutrition\nO: On ad lib demand feeds, breast and bottle. Abd. is round, soft with + BS, no loops. No spits. Voiding QS and passing loose green stool, guaiac -. Breast fed well X 2, with 40cc by bottle after AM breastfeeding. Difficulty latching at afternoon feed, but took 75cc by bottle. Breastfed well at 1830.\nA: Feeding well, breast and bottle\nP: Continue close observation and assessment of feeding. Follow daily wts.\n\n#4 Alt. in Parenting\nO: Mom in most of the day. Dad in X 2. Both were updated and questions answered. Dr. in and spoke with re circ. Mom signed consent and circ done. Instruction in circ. care done. Mom stated that she was given written instructions for circ. care. Mom is independent with breast and bottle feeding infant.\nA: Involved new learning to care for infant son\nP: informed and support.\n\n#5 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for feeds Q 4-4.5 hrs. Alert with cares. Appropriate tone and activity. Sucks well on pacifier. Breast and bottle feeding well. No spells. Sleeps well between cares. Circ. done. Tylenol given.\nA: Appropriate for term infant\nP: Continue to support developmental needs.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-12 00:00:00.000", "description": "Report", "row_id": 2020615, "text": "NNP Physical Exam\nAsleep in open crib. AFOF with good tone. BSC and equal on NC with comfortable techipnea and no retractions. No audible murmur, well perfused with normal pulses. ABD soft and rounded with active BS.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020605, "text": "Neonatology Attending Progress Note\n\nNow day of life 4, CA 6/7 weeks.\nOn 25ml of 100% O2 by nasal cannula.\nRR 40-60s CVS - HR 120-140s BP 78/45 56\n\nWt. 4185gm down 95gm\nON ad lib demand of breastfeeding and bottle feedings of 20\nFeedings well tolerated.\nDS 71\nNormal urine and stool output\n\nID - blood cultures still no growth.\nOn amp and gent for presumed pneumonia.\n\nAssessment/plan:\nBaby still requiring supplemental O2 for presumed pneumonia.\nWill continue to monitor closely.\nFamily meeting planned for today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020606, "text": "PCA 7am-7pm\n\n\n#2 RESP: Infant remains in nasal cannula, 25 cc, 100%. No\ndesats thus far, no spells thus far. O2 saturation stable,\n97-100%. Lung sounds clear and equal, mild subcostal\nretractions noted. A: Infant stable on nasal cannula. P:\nContinue to monitor for desats, spells, and increased work\nof breathing.\n\n#3 FEN: TF's remain ad lib, BM or 20. Infant feeds q 3-4\nhours. Breast fed well x2 and then bottled 20-74 cc each\ncare thus far. Abdomen is soft, active bowel sounds. No\nloops thus far, no spits thus far. Voiding with each care\nand stooling. D stick 66 before 12pm feeding. A: Infant is\ntolerating feeds well. P: Continue to monitor for feeding\nintolerance.\n\n#4 Parenting: in to visit for both cares thus far.\nIndependent with breastfeeding. Asking appropriate\nquestions. Family meeting this afternoon. A: Loving. P:\nContinue to educate and support family as needed.\n\n#5 G&D: Infant is swaddled in open air crib, temp stable.\nWakes for some feeds, alert and active. Sleeps well\ninbetween cares. Sucks on binki. Fontaneles soft and flat,\nmoves all extremities. A: AGA. P: Continue to promote growth\nand development of infant.\n\nSee flowsheet for further details.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020607, "text": "PCA 7am-7pm\nNPN 7a-7p\n\nI have examined this infant and agree with the above note by PCA O. Infant is currently in 13cc, NC. Infant continues on day of amp/gent. Bld cx remain negative to date. Infant showing no overt s/s of infection. Continue to treat with abx for seven days.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020608, "text": "Social Work\n\nMet briefly with today, doing well, very loving and invested. Mother is a nurse here on gyn floor. Couple live in , mother to be discharged today, have the parent room, and are interested in options for accomodation for tomorrow night as they have a long commute.\nWill speak with resource specialist to follow up with them. Coping well, very loving and invested, mother is breast feeding, supplementing.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020609, "text": "FAmily Meeting\nMet with in the family room today. See family meeting checklist for issues discussed. asked good questions and seemed to have an understanding of the issues.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-11 00:00:00.000", "description": "Report", "row_id": 2020610, "text": "NP NOTE\nPE: large term infant swaddled in open crib. Pink, well perfused in low flow nasal canula.\nAFOF sutures approximated eyes clear, nares patent, MMMP\nChest is symmetric with improved air exchane, comfortbale tachypnea.\nCV: RRR, soft systolic murmur, LUSB, pulses+2=\nAbd: soft with active bs\nGU: testes in scrotum\nEXT: well developed, MAE, PIV in place\nNeuro: active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-12 00:00:00.000", "description": "Report", "row_id": 2020611, "text": "Sepsis: Infant remains on ampi and gent, day 5 out of 7. No\ntemp instability noted. No s/s of infection noted. Continue\nto monitor for sepsis.\n\nResp: Infant remains in NC 100%, 13cc. RR: 30-60's. O2sat:\n92-100%. LS cl/=. Mild subcostal retractions noted. No\nspells thus far this shift. Continue to monitor respiratory\nstatus.\n\nFEN: Current weight 4145g (-40g). Infant on Ad-lib demand.\nBM/Sim20. Waking for feeds. Bottled 98, 12, and 55cc thus\nfar this shift + BFx1. Abd benign, soft, no loops. Voiding,\nno stool thus far. No spits noted. Continue to support\nnutrition needs.\n\n: in for 2nd cares. Loving and caring. Bath\ndemonstration done RN. Info given RN. Continue to\nupdate and support.\n\nG&D: Swaddled in OAC. Temps are stable. A&A w/ cares. Waking\nself q3-4h for feeds. Resting comfortably between cares.\nMAE. Brings hands to face. Settles with binki. Fontanels\nsoft and flat. Continue to monitor growth and development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-03-12 00:00:00.000", "description": "Report", "row_id": 2020612, "text": "NPN NIGHTS ADDENDUM\nAGREE WITH ABOVE ASSESSMENT AND PLAN. HEP B VACCINATION GIVEN. BABY TO HAVE CIRC LATER TODAY. GIVEN INFO ABOUT CIRC CARE. CONTINUE TO OBSERVE FOR ANY CHANGES IN EXAM. CONTINUE D/C TEACHING WITH . SIGNED UP FOR CPR NEXT FRIDAY.\n" }, { "category": "Nursing/other", "chartdate": "2189-03-12 00:00:00.000", "description": "Report", "row_id": 2020613, "text": "Neonatology Attending Progress Note\n\nNow day of life 5, CA weeks.\nIn 13cc of 100% O2 by nasal cannula.\nRR 30-70s\nCVS - HR 130-160s BP 81/51 61\n\nWt. 4145gm down 40gm on ad lib demand breastfeeding or Sim20.\nFeedings well coordinated and tolerated.\nNormal urine and stool output.\n\nID - day 5 of antibiotics for pneumonia.\n\nBili 8.5\n\nAssessment/plan:\nSteady progress.\nWith persistant O2 requirement will check CXR again to follow up.\nPlan is still for 7 days of therapy.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2138-09-09 00:00:00.000", "description": "Report", "row_id": 1530772, "text": "Nsg Admit Note 2130-0700\n\n46 yo female admitted to MICU from PACU after repeated attempted to wean from neo for hypotension and not successful. Transferred to MICU for further evaluation and treatment.\n\nPMH signif for morbid obesity with gastric bypass in with 250 lb weight loss, bilat PE s/p TPA in , DVT and , s/p paniculectomy in complicated by wound dehiscience, menorrhagia, discoid lupus, spinal stenosis with numbness to hip area.\n\nPt admitted for mult procedure including medial thigh lift, mastopexy,left arm scar revision and autologous fat transfer to face, thigh liposuction. Pt has been in chronic pain from spinal stenosis for 7 years and is on MS Contin .\nWhile in the PACU, pain was a major issue and pt also became hypotensive. Epidural was dc'd due to slow improvement and paresthesia. Pt started on ketamine gtt along with dilaudid PCA. Pt required neo to keep BP up despite IVF bolus'. Unable to wean neo so sent to MICU.\n\nCV - Pt afebrile. Continues to require neo for BP at 1.25 mcg/kg. Unable to wean at this time despite fluid bolus 500cc x2. Pt states her normal BP is 110/60. HR 60-70's NSR with no ectopy.\n\nResp - No O2 needed. BS cl bilat - sats 97-100%. No SOB. Strong spont non prod cough.\n\nGI - Tolerating ice chips and water very well. No nausea. Abd soft with hypoactive BS\n\nGU - Foley cath initially draining marginal amt cl yellow urine. Since bolus' - UO has picked up significantly.\n\nSkin - Incisions to front breast area and back with dsg intact but saturated with blood. No drainage or oozing however. Groin incision intact with dsgs that are dry and intact. Incisions to base of buttocks closed with skin seal and intact with no bleeding or drainage. Pt did get menstrual period during the night and pad placed. Surgibra placed on patient and pboots on. Levanox given SC for potential DVT.\n\nNeuro - Pt states pain in approx a . She is using her dilaudid frequently when awake. Ketamine in continuous and MS Contin was given at midnight. She also recieved xanax .5 mg. She is remarkably coherant and easy to arouse. She moves around in the bed easily and with minimal assist. She is very pleasant, cooperative and she is very knowledgable about her condition.\n\nSocial - Husband visited last evening and went home by midnight. He is very supportive and appropriate. She also has sisters who are supportive and available. She is a social worker at . They have no children.\n\nPlan - Continue to wean neo. Pt can go to the floor on ketamine if it is still necessary. Continue to explain all procedures to decrease anxiety.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2138-09-09 00:00:00.000", "description": "Report", "row_id": 1530773, "text": "MICU/SICU NPN\nPain: pt reports incisional pain primarilly from her chest as a at all times, ketamine gtt 1.7 mcg/kg/min, dilaudid PCA 0.5mg dose 6 min lockout 1 hr limit 5, at 1000 the PCA pump was cleared for a total of 45/54 attempts and a dose of 22.5mg, at 1600 there were an additional 18/18 attempts with a dose of 9 mg, pt is has also received mscontin at her home dose for chronic pain, morphine sulfate IR 30 mg and dilaudid 1mg IVP. pt has been consulted by APS. pain management has also been addressed by plastics and the MICU team. Pain management continues to be an issue for the pt. pt is able to move well in bed and up to chair despite high pain rating and appears comfortable at times.\n\nNuero/muscular: A&Ox3, moves all extremities appropriately, has regained all sensation in left leg, mentating appropriately, moving well in bed, able to stand with minimal assistance, up to chair for 2hrs\n\nCardio: HR: 59-77 NSR, BP 85-126/38-55, Neosynephrine titrated down from 1.25-0.75 mcg/kg/min throughout the shift, received one 500cc NS bolus, Hct at 1200 21.4, down from 24 at 0600, consented to transfusion, to receive 1 unit PRBC, CVP 10\n\nResp: Sats 94-100 on RA, pattern of breathing is regular and unlabored, breath sounds clear throughout all fields\n\nInteg: pt has four areas of incisional wounds, surgical dsgs are intact in all four areas, breasts are supported with a binder, small amt of serosanguinous drainage from this area, the most signifacant drainage is occuring from the wound in the left upper arm, dsg is fully saturated and weeping, incisions on the bilateral gluteal folds are covered with bonding, bilateral groin dsg is indicating scant drainage from this area. in addition to these incisional dsgs there are also two areas under her chin on either side which are covered with band-aids from facial fat injections\n\nGI/GU/fluid balance: foley draining adequate amts of clear yellow of clear yellow urine between 60-200cc/hr, +2136.0 for the 24hr period, taking po fluids, declined clear liquid tray, pt is passing flattus\n\nSocial: family in to visit throughout the day, husband, 2 sisters and mother, pt has reported frustrations with her pain management, particularly with regards to the recommendations of APS, due to her chronic pain pt is very concerned in the proper management of this issue\n\nPlan: continue to follow pain regiment and follow-up with ongoing recommendations, encourage po's and advancing diet as tolerated, post transfusion hct, continue to tritate neosynephrine for a minimum sbp of 90\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2138-09-10 00:00:00.000", "description": "Report", "row_id": 1530774, "text": "NURSING PROGRESS NOTE 1900-0700\nEVENTS: PT 1 UNIT PRBC'S AT BEGINNING OF THE SHIFT FOR HCT 21.7. REPEAT HCT POST TRANSFUSION 22.8, SO SECOND UNIT OF PRBC'S GIVEN. AM LABS SENT, HOWEVER CBC NOT DRAWN - TO BE CHECKED POST-TRANSFUSION. NEO GTT TITRATED FROM 0.6MCG/KG/MIN TO 0.4MCG/KG/MIN - SBP STABLE AT > 90 AND MAPS > 60. ATTEMPTED TO WEAN TO 0.2MCG/KG/MIN - SBP DIPPED TO 89 WITH MAP OF 53, SO INCREASED BACK UP TO 0.4MCG/KG/MIN.\n\nNEURO: PT ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. MAE X4. RECEIVED PT OOB IN CHAIR, RETURNED TO BED WITH MINIMAL ASSIST. DENIES ANY NUMBNESS OR TINGLING. TMAX 100.5 AT , DOWN TO 98.9 AT 0400.\n\nCV: HR 60'S-80'S NSR WITHOUT ECTOPY NOTED. PT WAS NOTED TO HAVE BRIEF DIP IN HR TO 40'S - SELF LIMITING AND RESOLVED WITHOUT INTERVENTION. DENIES CP. NEO GTT CURRENTLY INFUSING AT 0.4MCG/KG/MIN, SBP 90'S-120'S AND MAPS >60 EXCEPT AS NOTED ABOVE. PALPABLE RADIAL/DP PULSES BILATERALLY.\n\nRESP: LUNG SOUNDS ESSENTIALLY CLEAR THROUGHOUT. DENIES SOB, NO INCREASED WOB NOTED. SPO2 > OR = 95% ON ROOM AIR.\n\nGI/GU: ABDOMEN SOFT, BOWEL SOUNDS PRESENT X4. PT ABLE TO TOLERATE TOAST AND CLEARS AT THIS TIME, DENIES ANY NAUSEA. NO STOOL THIS SHIFT. INDWELLING FOLEY CATHETER PATENTLY DRAINING ADEQUATE AMTS OF CLEAR YELLOW URINE.\n\nINTEG: PT HAS MULTIPLE SURGICAL INCISION SITES COVERED WITH DSD'S. ALL ARE INTACT AND BLOOD STAINED. SEROUS-SANGUINOUS DRAINAGE OOZING FROM LEFT ARM INCISION AND RIGHT GROIN DSG REINFORCED. NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nPAIN: C/O GENERALIZED INCISIONAL ACHING, GREATEST DISCOMFORT IS IN RIGHT LEG. STARTED PO LYRICA TONIGHT, MS CONTIN GIVEN AS ORDERED. PCA PUMP SET AT 0.5MG/6MINUTE LOCKOUT/1HOUR LIMIT OF 5MG. KETAMINE GTT INFUSING AT 1.7MCG/KG/MIN. PAIN SCORE AT 0400 - PT STATES SHE IS COMFORTABLE AND SHE APPEARS TO BE COMFORTABLE.\n\nSOCIAL: HUSBAND IN TO VISIT THIS EVENING. ALL QUESTIONS ANSWERED APPROPRIATELY. PT EXPRESSED CONCERN ABOUT FAMILY MEMBERS - EXCLUDING HER HUSBAND - REGARDING RECEIVING BLOOD TRANSFUSIONS. PT REASSURED OF PRIVACY REGARDING HER CARE EXCEPT TO THOSE AUTHORIZED TO RECEIVE INFORMATION.\n\nPLAN: CONTINUE ICU SUPPORTIVE CARE. MONITOR BP, TITRATE NEO GTT TO GOAL SBP OF 90 OR HIGHER AND MAPS OF 60 OR HIGHER. RECHECK HCT POST TRANSFUSION - PRBC'S SHOULD BE COMPLETED AT APPROX 0645. CONTINUE TO MANAGE PAIN PER PAIN SERVICE RECOMMENDATIONS. ENCOURAGE PO'S. ENCOURAGE PT TO GET OOB AND CDB. FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2138-09-10 00:00:00.000", "description": "Report", "row_id": 1530775, "text": "MICU/SICU NPN\nPain: pain has been well controled throughout the shift, ketamine gtt and pca d/c'd at 1000, prior to d/c pt was using pca very infrequently receiving 13.5mg from 0700, transitioned to po dilaudid and oxycodone prn, chief source of discomfort is a burning sensation in groin believed to be caused by tape, pt expressed concerned to plastics, pt reports pain as very managable at a , has received no prns for pain since 1330\n\nNuero/Muscl: ambulated x3, up in chair most of the day, moving with minimal assist/supervision\n\nCardio: HR: 52-79 NSR, BP: 86-113/41-59, post transfusion hct obtained following the 2 units PRBC received overnight, 1100 hct 25.5 up from 21.8 at 0000, neosynephrine d/c'd at 1000, since that time has had occasional systolic dips into the 80s, has received 2 500cc bolus, denies dizziness when standing/ambulating\n\nResp: Sats 96-100 on RA, breath sounds clear throughout all lung fields, breathing is regular and unlabored at rest and with activity\n\nInteg: surgical dsgs were changed by plastics at the beginning of the shift and remain dry and intact, dsg in pt's groin was not changed, area continues to cause pt discomfort, as discussed expressed her concerns with plastics, in response her stitches in the area were modified in an effort to increase her comfort, pt also has an area of skin impairment on her right upper arm from the blood pressure cuff, appears to be an abrasion, the area is now covered with a tegaderm\n\nGI/GU: pt has yet to have a post-op BM, is passing flatus, diet has been advanced from clear liquids to DAT\n\nPlan: maintain pt's blood pressure over 90 systolic, advance diet, continue to encourage activity as tolerated\n" }, { "category": "Radiology", "chartdate": "2138-09-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 978889, "text": " 5:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ASSESS FOR LINE PLACEMENT.\n Admitting Diagnosis: MASSIVE WEIGHT LOSS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with left subclavian line placed\n REASON FOR THIS EXAMINATION:\n assess for line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:46 P.M. ON \n\n HISTORY: Left subclavian line placement.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the left subclavian line projects over the upper SVC. A linear\n radiopaque marker stripe runs vertically to the right of the midline, and\n could be a nasogastric tube. Clinical correlation advised.\n\n Lungs clear. Heart size normal. No pleural abnormality or mediastinal\n widening\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2198-11-02 00:00:00.000", "description": "DUPLEX DOP ABD/PEL LIMITED", "row_id": 1220102, "text": " 1:35 PM\n RENAL U.S. PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: pls eval vasculature, extrinsic compression, parenchymal arc\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57F new oliguria ?history ureteral stenosis/renal mass\n REASON FOR THIS EXAMINATION:\n pls eval vasculature, extrinsic compression, parenchymal architecture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 57-year-old female, please evaluate vasculature, parenchymal\n architecture.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The right kidney measures 9.4 cm and demonstrates no\n hydronephrosis. No gross renal abnormality is seen on limited views.\n Appropriate arterial, venous, and waveforms are identified.\n\n IMPRESSION: No gross abnormality is seen in the right kidney on limited\n views. The exam was not completed due to being canceled by the clinical team\n during performance.\n\n" }, { "category": "ECG", "chartdate": "2198-11-10 00:00:00.000", "description": "Report", "row_id": 268389, "text": "Sinus tachycardia with baseline artifact. Compared to the previous tracing\nof there is no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2198-11-04 00:00:00.000", "description": "Report", "row_id": 268390, "text": "Sinus tachycardia. Non-specific lateral ST segment changes. Compared to the\nprevious tracing of lateral T wave changes are new and heart rate is\nfaster.\n\n" }, { "category": "ECG", "chartdate": "2198-11-01 00:00:00.000", "description": "Report", "row_id": 268622, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2105-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660761, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 02:24 PM\n Events:\n - had L thigh pain, no obvious cause at this time\n - CT scan negative for RP bleed\n - CT chest not done\n - IR recommended leaving catheters in for one more day in case they\n would look again tomorrow and do more TPA treatment\n - given lasix to see if respiratory status improved, had good urine\n output, then was able to be weaned from facemask to 6L NC overnight\n - vanco level 21.4; changed to 750 mg dosing\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:42 PM\n Ciprofloxacin - 10:42 PM\n Aztreonam - 04:03 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 AM\n Furosemide (Lasix) - 06:15 PM\n Heparin Sodium - 11:13 PM\n Lorazepam (Ativan) - 03:03 AM\n Hydromorphone (Dilaudid) - 06:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (83 - 115) bpm\n BP: 118/48(65) {104/44(61) - 158/77(101)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,003 mL\n 1,047 mL\n PO:\n TF:\n IVF:\n 4,719 mL\n 1,047 mL\n Blood products:\n 284 mL\n Total out:\n 4,470 mL\n 770 mL\n Urine:\n 4,470 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 533 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 297 K/uL\n 7.2 g/dL\n 95 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 21.0 %\n 9.0 K/uL\n [image002.jpg]\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n 09:54 AM\n 02:28 PM\n 04:32 AM\n WBC\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n 10.2\n 11.1\n 9.0\n Hct\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n 22.1\n 23.7\n 21.0\n Plt\n 371\n 375\n 313\n \n 313\n 297\n Cr\n 1.4\n 1.5\n 1.4\n TropT\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 14\n 95\n Other labs: PT / PTT / INR:15.7/70.4/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660763, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 02:24 PM\n Events:\n - had L thigh pain, no obvious cause at this time\n - CT scan negative for RP bleed\n - CT chest not done\n - IR recommended leaving catheters in for one more day in case they\n would look again tomorrow and do more TPA treatment\n - given lasix to see if respiratory status improved, had good urine\n output, then was able to be weaned from facemask to 6L NC overnight\n - vanco level 21.4; changed to 750 mg dosing\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:42 PM\n Ciprofloxacin - 10:42 PM\n Aztreonam - 04:03 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 AM\n Furosemide (Lasix) - 06:15 PM\n Heparin Sodium - 11:13 PM\n Lorazepam (Ativan) - 03:03 AM\n Hydromorphone (Dilaudid) - 06:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (83 - 115) bpm\n BP: 118/48(65) {104/44(61) - 158/77(101)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,003 mL\n 1,047 mL\n PO:\n TF:\n IVF:\n 4,719 mL\n 1,047 mL\n Blood products:\n 284 mL\n Total out:\n 4,470 mL\n 770 mL\n Urine:\n 4,470 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 533 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding, no grey- or cullen\ns signs\n Extremities: Right: 2+, Left: 2+, no evidence of fem hematoma\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli,\n Labs / Radiology\n 297 K/uL\n 7.2 g/dL\n 95 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 21.0 %\n 9.0 K/uL\n [image002.jpg]\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n 09:54 AM\n 02:28 PM\n 04:32 AM\n WBC\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n 10.2\n 11.1\n 9.0\n Hct\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n 22.1\n 23.7\n 21.0\n Plt\n 371\n 375\n 313\n \n 313\n 297\n Cr\n 1.4\n 1.5\n 1.4\n TropT\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 14\n 95\n Other labs: PT / PTT / INR:15.7/70.4/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660577, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 03:18 PM\n EKG - At 04:50 PM\n BLOOD CULTURED - At 05:00 PM\n TRANS ESOPHAGEAL ECHO - At 05:00 PM\n Events:\n - renal recommended not to do CTA bc dye load, will get CT n/c chest in\n AM to eval PNA\n - patient around 6pm had chest pain, TWI in V1,2, cardiology notified,\n no MI, started heparin drip with weight based protocol\n - continuing to cycle enzymes\n - IR placed power PICC, now appropriately positioned\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Ciprofloxacin - 10:00 PM\n Aztreonam - 03:18 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Heparin Sodium - 12:53 AM\n Lorazepam (Ativan) - 03:17 AM\n Hydromorphone (Dilaudid) - 05:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.8\n HR: 90 (85 - 119) bpm\n BP: 117/49(64) {108/40(55) - 161/74(91)} mmHg\n RR: 15 (11 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,514 mL\n 1,705 mL\n PO:\n TF:\n IVF:\n 8,514 mL\n 1,529 mL\n Blood products:\n 175 mL\n Total out:\n 1,910 mL\n 280 mL\n Urine:\n 1,760 mL\n 280 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 6,604 mL\n 1,425 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 300 K/uL\n 7.0 g/dL\n 114 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 20.2 %\n 10.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n WBC\n 11.7\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n Plt\n 384\n 371\n 375\n \n Cr\n 1.5\n 1.4\n 1.5\n TropT\n 0.02\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 73\n 114\n Other labs: PT / PTT / INR:16.2/35.0/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis and Post-procedure mgmt: s/p TPA by IR with question\n of anaphylaxis. Procedure complicated by tachycardia, hypoxemia.\n Transferred to ICU for monitoring. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure. Possible\n aspiration PNA on CXR . Low suspicion for MI by history and will\n continue to rule out with serial enzymes. Lastly might represent CHF\n given e/o volume overload on exam and h/o diastolic dysfunction,\n however abnormalities on CXR appear unilateral.\n - 0.5mg/hr TPA on each side for total of 1.0mg/hr\n - 250 units heparin gtt per hour for each sheeth (total 500)\n - no other heparin products to be given\n - Avoid blood draws, arterial sticks or arterial lines\n - frequent neuro checks q2 hours for stroke\n - Coags and fibrinogen q3 hours, h/h q6 hours\n - If fibrinogen < 150, decrease by and recheck in 1 hour.\n - If firbinogen < 100, stop TPA and call IR, can draw from sheaths as\n long as it is flushed with saline.\n - 40mg Prednisone 16, 8 and 2 hour pre-procedure - plan for 10am today\n - 150mg zantac 1 hour pre-procedure\n - 15mg PO benadryl 1 hour pre-procedure\n .\n #Hypoxemia: PE vs. aspiration vs. CHF vs obsesity hypoventilation and\n derecruitment in setting of procedure and sedation. PE high-risk given\n clot burden and peri-procedure; aspiration/HAP given body habitus,\n leukocytosis and low grade fever; CHF less likely given unilateral\n findings on CXR, BNP.\n - check ABG today\n - trial on venti-mask to assess O2 requirements\n - send sputum cxs\n - vanc//cipro for HAP/aspiration\n - if can obtain PIV access will perform CTA to investigate PE (would\n require more aggressive anticoagulation) and venogram to investigate\n status of IVC. If only have PICC access will perform non-contrast CT\n (investigate pulmonary infiltrate) and venogram.\n .\n #Renal Failure: Baseline Cr 1.1. Likely pre-renal complicated by ATN\n from contrast nephropathy. Renal ultrasound without obstruction.\n - IVF's, mucomyst, bicarbonate pre-procedure\n - renal ultrasound without obstruction\n .\n #Hypertension: Has h/o HTN. Received one dose of hydralazine PM\n as low suspicion for MI, and beta-blockade in setting of PE may\n precipitate hypotension.\n - will add home regimen as BP tolerates\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs for promotility. Will d/w GI re why\n not reglan or erythromycin.\n - continue promethazine and dilaudid prn\n - Gastritis - H. Pylori neg, treating with PPI daily\n .\n # UTI: Treated and resolved, follow Cr.\n .\n # Anemia: Continues to trend down and started on Fe replacement.\n Negative EGD. Will need to trend hematocrit on TPA and heparin.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - Pt unable to tolerate bowel prep now (nausea, renal failure), but if\n diarrhea or worsening anemia persists, will need colonoscopy\n .\n # CAD: Known non-obstructive CAD on recent cath. Normal recent ECHO and\n stress test. Given chest pain on presentation will cycle enzmes -> CEs\n negative.\n - no aspirin given allergy\n - continue statin\n - will add BP meds as tolerated\n .\n # Diabetes: Poorly controlled even while NPO. Takes 100 units glargine\n qhs\n - HbA1C 10.8 , 7.9 \n - start insulin gtt given poor control of BS\n - Diabetic diet\n .\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n .\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet,IVF, lytes prn\n # Access: PICC, 2 femoral sheaths, will attempt to get PIV access for\n CTA\n # PPx: heparin IV infusion, TPA, no other heparin products at this time\n -> will need to transition to long-term anticoagulation based on CTA\n results\n # Code: presumed FULL\n # Dispo: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Echo", "chartdate": "2105-03-20 00:00:00.000", "description": "Report", "row_id": 87727, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function.\nHeight: (in) 65\nWeight (lb): 236\nBSA (m2): 2.12 m2\nBP (mm Hg): 90/60\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 09:29\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\nPhysiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion. There is\nno valvular aortic stenosis. The increased transaortic velocity is likely\nrelated to high cardiac output. No aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. Physiologic mitral regurgitation is seen (within\nnormal limits). The pulmonary artery systolic pressure could not be\ndetermined. There is a small pericardial effusion, which is not\nhemodynamically-significant.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Small\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the amount of\npericardial fluid has slightly increased. The other findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2105-03-25 00:00:00.000", "description": "Report", "row_id": 87648, "text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function.\nHeight: (in) 65\nWeight (lb): 236\nBSA (m2): 2.12 m2\nBP (mm Hg): 143/65\nHR (bpm): 116\nStatus: Inpatient\nDate/Time: at 16:26\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion. There is no valvular\naortic stenosis. The increased transaortic velocity is likely related to high\ncardiac output. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The estimated pulmonary\nartery systolic pressure is normal. There is a small pericardial effusion.\nThere are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1063488, "text": " 3:58 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: placement.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with replaced right picc line. urgent need to use for\n medication.\n REASON FOR THIS EXAMINATION:\n placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Replaced right PICC.\n\n FINDINGS: Bedside frontal chest radiograph demonstrates a new right PICC with\n the tip terminating in the azygos vein. Otherwise, there may be slight\n improvement in the diffuse bilateral pulmonary edema. The heart is enlarged.\n\n IMPRESSION: PICC terminating in azygos vein.\n\n Findings discussed with Dr. at 7 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2105-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063934, "text": " 9:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PTX, mediastinum, infiltrate\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with chest pain and shortness of breath\n REASON FOR THIS EXAMINATION:\n ?PTX, mediastinum, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Chest pain and shortness of breath.\n\n REFERENCE EXAM: .\n\n FINDINGS: The heart is moderately increased in size, and there is pulmonary\n vascular redistribution with alveolar infiltrates in both lower lungs. There\n is a small right pleural effusion. There is no left effusion.\n\n IMPRESSION: CHF and underlying infectious infiltrate cannot be totally\n excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063355, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate, edema, effusion\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman s/p IR procedure for IVC clot, increased O2 requirements\n REASON FOR THIS EXAMINATION:\n ?infiltrate, edema, effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:54 A.M.\n\n HISTORY: IR procedure for IVC clot, question infiltrate or edema.\n\n IMPRESSION: AP chest compared to and .\n\n Diffuse pulmonary opacification has worsened since , progressing\n to consolidation in the right upper and lower lobes, with a more interstitial\n and heterogeneous quality in the left lung. The simplest explanation is\n pulmonary edema, asymmetrically distributed, sometimes a feature of mitral\n regurgitation. Alternatively, the patient could be developing fulminant\n pneumonia in the right lung, particularly and mild edema elsewhere. Heart is\n mildly enlarged, unchanged. No pneumothorax or appreciable pleural effusion.\n Findings were discussed by telephone with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-19 00:00:00.000", "description": "RENAL U.S.", "row_id": 1062461, "text": " 4:35 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please eval patency of renal arteries and veins. WITH DOPPLE\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with renal failure, peripheral edema, h/o hypercoagulability\n REASON FOR THIS EXAMINATION:\n please eval patency of renal arteries and veins. WITH DOPPLERS PLEASE\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 5:25 PM\n No evidence of renal artery stenosis. Elevated resistive indices of\n segmental vessels supplying both kidneys suggests chronic intraparenchymal\n disease. Normal ultrasound appearance of kidneys and bladder.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with renal failure, peripheral edema and\n history of hypercoagulability.\n\n COMPARISON: Renal ultrasound of .\n\n RENAL ULTRASOUND WITH DOPPLER EVALUATION: The right kidney measures 11.7 cm\n and the left kidney measures 10.7 cm. Both are normal without hydronephrosis,\n stones, or masses. The urinary bladder is well distended and normal in\n appearance.\n\n DOPPLER EXAMINATION: Color and Doppler ultrasound was used to evaluate the\n vessels of both kidneys. On the right, the main renal artery demonstrates a\n rapid upstroke and forward flow during diastole. Resistive indices were\n measured in the intraparenchymal vessels supplying the upper, mid and lower\n poles, and measure 0.86, 0.81 and 0.84, respectively. Normal flow and\n waveform is noted of the right main renal vein.\n\n On the left, flow in the main renal artery demonstrates a rapid upstroke and\n forward flow during diastole. Resistive indices were measured in the\n intraparenchymal vessels feeding the upper, mid and lower poles, measuring\n 0.74, 0.79 and 0.79, respectively. Normal flow is seen in the left main renal\n vein.\n\n IMPRESSION:\n\n 1. Normal kidneys and bladder.\n\n 2. No evidence of renal artery stenosis. Elevated resistive indices of the\n intraparenchymal vessels suggest chronic parenchymal disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-19 00:00:00.000", "description": "RENAL U.S.", "row_id": 1062462, "text": ", W. MED FA2 4:35 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please eval patency of renal arteries and veins. WITH DOPPLE\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with renal failure, peripheral edema, h/o hypercoagulability\n REASON FOR THIS EXAMINATION:\n please eval patency of renal arteries and veins. WITH DOPPLERS PLEASE\n ______________________________________________________________________________\n PFI REPORT\n No evidence of renal artery stenosis. Elevated resistive indices of\n segmental vessels supplying both kidneys suggests chronic intraparenchymal\n disease. Normal ultrasound appearance of kidneys and bladder.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1063339, "text": " 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for evidence of aspiration, PE\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with IVC thrombosis w/ hypoxemia s/p IR procedure\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of aspiration, PE\n ______________________________________________________________________________\n WET READ: DSsd TUE 8:53 PM\n new bilateral diffuse airspace opacity. Cardiogenic causes should be\n considered given increased heart size, but noncardiogenic (e.g. ARDS) cannot\n be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:11 P.M., \n\n HISTORY: IVC thrombosis and hypoxemia.\n\n IMPRESSION: AP chest compared to :\n\n Vascular engorgement in the lungs and diffuse interstitial abnormality suggest\n new pulmonary edema. Mild cardiomegaly is stable. No appreciable pleural\n effusion or pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-26 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1063582, "text": " 10:44 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: pls assess for RP bleed\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman recent TPA/heparin administration, precipitous HCT drop\n REASON FOR THIS EXAMINATION:\n pls assess for RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:02 PM\n no RP bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent heparin and TPA administration, now with precipitous\n hematocrit drop. Please assess for retroperitoneal hemorrhage.\n\n COMPARISON: , and MRV from .\n\n TECHNIQUE: Volumetric CT acquisition of the abdomen and pelvis was performed\n without oral or intravenous contrast. Multiplanar reformatted images were\n obtained and reviewed.\n\n CT ABDOMEN: There are small bilateral pleural effusions, and associated\n bibasilar atelectasis. Ground-glass opacity in the right middle lobe and\n lingula is consistent with recent chest radiographs demonstrating pulmonary\n edema.\n\n Absence of intravenous contrast limits evaluation of the abdominal parenchymal\n organs and vasculature. There is CT evidence of anemia. Non-contrast\n appearance of the liver is unremarkable. There is no biliary ductal\n dilatation. Trace ascites is seen throughout the abdomen, and there is\n diffuse anasarca in the subcutaneous tissues. Multiple nodular densities in\n the lower abdominal wall are consistent with recent subcutaneous injections.\n Gallbladder is surgically absent. The pancreas is atrophic and fatty\n replaced. Spleen, adrenal glands, and kidneys have normal non-contrast\n appearance. Stomach and intra-abdominal loops of bowel are normal. There is\n no free intraperitoneal air or abnormal intra-abdominal lymphadenopathy. IVC\n filter is unchanged in position.\n\n CT PELVIS: There is no sign of retroperitoneal hemorrhage. Pelvic loops of\n large and small bowel are unremarkable. Urinary bladder is decompressed, with\n Foley catheter balloon in place. Trace free fluid is seen within the pelvis,\n consistent with ascites. There is no abnormal pelvic or inguinal\n lymphadenopathy. Bilateral femoral approach central venous catheters are in\n place, with tips in the external iliac veins bilaterally. Subcutaneous lipoma\n anterior to the right ilium is unchanged.\n\n Osseous structures are unchanged. There is no osseous lesion suspicious for\n malignancy.\n\n IMPRESSION:\n (Over)\n\n 10:44 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: pls assess for RP bleed\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No retroperitoneal hemorrhage.\n 2. Trace ascites. Anasarca.\n 3. Small bilateral pleural effusions, atelectasis, and ground-glass opacity,\n most consistent with pulmonary edema.\n 4. Unchanged infrarenal IVC filter. Known IVC thrombus below the level of\n the filter is better depicted and described on recently performed MRV from\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-24 00:00:00.000", "description": "INTERUP IVC", "row_id": 1063220, "text": " 9:56 AM\n IVC GRAM Clip # \n Reason: known IVC filter, thrombectomy and tPA lysis per interventio\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: VISAPAQUE Amt: 55\n ********************************* CPT Codes ********************************\n * INTERUP IVC TRANSCATHETER INFUSION FOR LYS *\n * SECONDARY THROMBECTOMY ARTERIA INJ EXTREMITY VENOGRAM *\n * INJ EXTREMITY VENOGRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EXTREM BILAT VENOGRAPHY PERC PLCMT IVC FILTER *\n * TRANSCATHETER INFUSION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with IVC filter clot\n REASON FOR THIS EXAMINATION:\n known IVC filter, thrombectomy and tPA lysis per interventional radiology\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMPd TUE 11:16 PM\n Large amount of thrombus in the IVC extending to the external iliac veins\n bilaterally. During this procedure, the patient developed throat tightness\n and hypoxia after infusion of TPA through the AngioJet and dropped O2\n saturations to the low 80s. She responded to 100% O2 non-rebreather.\n Infusion catheters were placed and TPA and heparin were both started. It is\n believed that her symptoms during the case represented either PE or contrast\n reaction.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 40-year-old woman with history of IVC filter placement\n and subsequent development of clot in the IVC and common iliac veins. Request\n is made for thrombectomy and thrombolysis.\n\n FELLOW: Dr. .\n\n STAFF RADIOLOGIST: Dr. who was present and supervised the\n entire procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n a total of 275 mcg of fentanyl and 5 mg of Versed throughout the total\n intraservice time of 2 hours 45 minutes during which the patient's hemodynamic\n parameters were continuously monitored. 1% lidocaine was given for local\n anesthesia.\n\n PROCEDURE AND FINDINGS: After review of the risks and benefits of the\n procedure, informed consent was obtained. Because the patient had a prior\n history of allergic reaction to contrast, she was pretreated with IV\n hydrocortisone and Benadryl. Both groins were both prepped and draped in the\n usual sterile fashion. Access was obtained into the right groin with\n ultrasound guidance using a micropuncture needle through which a 0.018 wire\n was passed. The system was upsized to a 0.035 Amplatz wire and a 7 French x\n 23 cm sheath. The wire was able to negotiate through the external iliac,\n common iliac, and inferior vena cava. The side arm was attached to a flush.\n Access was also obtained on the left common femoral vein via similar\n (Over)\n\n 9:56 AM\n IVC GRAM Clip # \n Reason: known IVC filter, thrombectomy and tPA lysis per interventio\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: VISAPAQUE Amt: 55\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n procedure. Bilateral venograms were performed.\n\n On the right, there is high-grade stenosis of the common iliac vein. On the\n left, there is occlusion of the common iliac vein. Numerous small collateral\n vessels are seen bilaterally. Within the IVC, there is a large amount of\n thrombus inferior to the filter which us located below the renal veins.\n\n Mechanical thrombolysis of the right and left common iliac vein and the IVC\n was performed through both access sheaths with the angiojet device. A total\n of 15 mg of tPA was then infused into the right and left common iliac\n vein and IVC through the angiojet on the pulse spray setting. Immediatly\n following the infusion of tPA the patient developed hypoxia down to low 80s\n oxygen saturation, throat tightness, and transient tachycardia up to the 150s.\n She was given 50 mg IV Benadryl. Her oxygen saturation improved into the\n mid-90s on a 100% nonrebreather mask. She also complained of intermittent\n cough until the end of the procedure. At this point, the decision was made\n not to give further contrast in case this represented an allergic reaction.\n TPA infusion catheters with 30 cm infusion length were placed bilaterally\n through each sheath. The length of infusion extends from the superior portion\n of the IVC through the external iliac veins bilaterally. The infusion was\n started at 0.5 mg/hour through each catheter. 250 units/hour of heparin were\n also administered through each sheath side arm. The sheath and catheters were\n fixed to the skin with 2-0 silk sutures and sterile dressings. The patient\n was taken to the intensive care unit in stable condition with continued\n oxygen requirment.\n\n IMPRESSION:\n 1. Inferior venacavogram and bilateral pelvic venograms demonstrating large\n amount of thrombus in the IVC and common iliac veins.\n\n 2. During the procedure, the patient developed throat tightness, hypoxia,\n transient tachycardia, and cough. She was treated with IV Benadryl. The\n symptoms represent either pulmonary embolism or contrast reaction.\n\n 3. TPA infusion catheters placed. The patient should remain on TPA and\n heparin drips overnight.\n\n PLAN: We will re-study the pelvic veins and the IVC tomorrow. She will need\n to be re-treated with prophylaxis for contrast reaction and also for\n prevention of contrast-induced nephropathy. The findings were conveyed to the\n MICU team at the end of the procedure.\n\n\n\n\n (Over)\n\n 9:56 AM\n IVC GRAM Clip # \n Reason: known IVC filter, thrombectomy and tPA lysis per interventio\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: VISAPAQUE Amt: 55\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2105-03-24 00:00:00.000", "description": "INTERUP IVC", "row_id": 1063221, "text": ", W. MED FA2 9:56 AM\n IVC GRAM Clip # \n Reason: known IVC filter, thrombectomy and tPA lysis per interventio\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: VISAPAQUE Amt: 55\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with IVC filter clot\n REASON FOR THIS EXAMINATION:\n known IVC filter, thrombectomy and tPA lysis per interventional radiology\n ______________________________________________________________________________\n PFI REPORT\n Large amount of thrombus in the IVC extending to the external iliac veins\n bilaterally. During this procedure, the patient developed throat tightness\n and hypoxia after infusion of TPA through the AngioJet and dropped O2\n saturations to the low 80s. She responded to 100% O2 non-rebreather.\n Infusion catheters were placed and TPA and heparin were both started. It is\n believed that her symptoms during the case represented either PE or contrast\n reaction.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-12 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 1061023, "text": ", W. MED FA2 2:09 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LEFT CALF SWELLING, EVAL FOR DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with peripheral edema, left calf tenderness\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in the left lower extremity. Subcutaneous edema in the\n left calf.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1063521, "text": " 8:26 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PICC placement\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with PICC repositioning\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with the earlier study of this date, it is extremely\n difficult to see the precise position of the central catheter, which may be in\n the azygos vein as on the previous study. An oblique or even lateral view\n would be helpful for further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-21 00:00:00.000", "description": "MRV ABDOMEN W/O CONTRAST", "row_id": 1062846, "text": " 10:11 PM\n MRV ABDOMEN W/O CONTRAST Clip # \n Reason: Please evaluate for possible clot of IVC filter. Of note, th\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with a history of possible protein C deficiency and possible\n prior PE with a longstanding IVC filter in place off of anticoagulation with\n progressive lower extremity edema and new renal failure concerning for\n complication of clotting of IVC filter.\n REASON FOR THIS EXAMINATION:\n Please evaluate for possible clot of IVC filter. Of note, the patient is in\n acute renal failure, has a dye allergy and is unable to have peripheral IV's\n placed and therefore all contrast studies (CT or MRI) are unable to be\n performed, therefore we need a non-contrast evaluation of the IVC filter.\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure, dye allergy, unable to place peripheral IV\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of possible protein C deficiency and prior\n PE with longstanding IVC filter in place. Progressive lower extremity edema\n and new renal failure. Assess thrombosis.\n\n COMPARISON: CT abdomen and pelvis of .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen and pelvis\n were obtained at 1.5 Tesla. Gadolinium was not administered due to acute\n renal failure.\n\n MRV OF THE LOWER ABDOMEN AND PELVIS: From the renal veins and above, the\n inferior vena cava is patent. The renal veins are patent as well. However,\n from the level of the filter inferiorly, the inferior vena cava is thrombosed,\n with thrombosis extending into bilateral common iliac veins. On the right,\n thrombosis extends through the common iliac vein to the bifurcation, as seen\n on FIESTA images. The right external iliac vein is largely free of thrombus,\n through the imaged common femoral vein. The right internal iliac vein is\n partially thrombosed at its origin, and thrombus extends into at least one of\n the right internal iliac vein branches.\n\n On the left, thrombus fills and expands the left common iliac vein to the\n bifurcation. The left external iliac vein is partially occluded with\n thrombus, particularly in its mid portion extending to the common femoral\n vein. At approximately the level of the inguinal ligament, the left common\n femoral vein then becomes patent. The left internal iliac vein appears free\n of thrombus.\n\n There is limited visualization of the abdominal and pelvic structures. The\n bladder is unremarkable. The uterus is noted to contain a fundal fibroid,\n measuring about 2.8 cm. The ovaries are not well visualized. Pelvic bowel\n loops are unremarkable on the limited sequences obtained, except for the\n occasional colonic diverticulum. There is no hydronephrosis of the kidneys.\n (Over)\n\n 10:11 PM\n MRV ABDOMEN W/O CONTRAST Clip # \n Reason: Please evaluate for possible clot of IVC filter. Of note, th\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Multiplanar images provided multiple perspectives for the above findings.\n\n IMPRESSION: Thrombosis of the inferior vena cava below the IVC filter,\n extending into both common iliac veins. Thrombus does extend into the right\n internal iliac vein and into the left external iliac vein as described.\n\n Findings were discussed with Dr. at the time of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-12 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 1061022, "text": " 2:09 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LEFT CALF SWELLING, EVAL FOR DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with peripheral edema, left calf tenderness\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:11 PM\n No evidence of DVT in the left lower extremity. Subcutaneous edema in the\n left calf.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Peripheral edema and left calf tenderness.\n\n There are no prior left lower extremity ultrasounds for comparison.\n\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the left\n common femoral, superficial femoral and popliteal veins were performed.\n Normal flow, augmentation, compressibility and waveforms are demonstrated. No\n intraluminal thrombus is identified.\n\n Subcutaneous edema is seen in the left calf.\n\n IMPRESSION: No evidence of DVT in the left lower extremity. Subcutaneous\n edema in the left calf.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-30 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1064316, "text": " 1:58 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please eval up to groin, for recanalization or DVTs.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with large IVC filter clot, s/p attempted thrombolectomy,\n with extensive peripheral edema and pain at bilateral groin entry for TPA\n sites.\n REASON FOR THIS EXAMINATION:\n Please eval up to groin, for recanalization or DVTs.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female with lower extremity edema and pain status\n post attempted thrombolectomy and IVC filter placement.\n\n COMPARISON: Left leg ultrasound, .\n\n FINDINGS: -scale color and Doppler son of bilateral common femoral,\n superficial femoral, and popliteal veins were performed. There is normal\n compression and flow identified in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-04-03 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1065218, "text": " 1:27 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: please evaluate for RUE DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with known IVC clot and right arm PICC line with erythema and\n induration\n REASON FOR THIS EXAMINATION:\n please evaluate for RUE DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc FRI 3:15 PM\n No evidence of DVT seen in the right upper extremity. Right basilic PICC in\n place.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old female with known IVC clot abdomen with right arm PICC,\n now with right arm erythema and induration concerning for DVT.\n\n COMPARISON: None available.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and color and pulsed wave\n Doppler examination was performed over the left subclavian vein as well as the\n right internal jugular, subclavian, axillary, brachial, basilic, and cephalic\n veins. A right brachial PICC is in place. The study demonstrates normal\n flow, compressibility and respiratory variation. No intraluminal thrombus is\n seen.\n\n IMPRESSION: No evidence of DVT seen in the right upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2105-04-03 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1065219, "text": ", W. MED FA2 1:27 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: please evaluate for RUE DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with known IVC clot and right arm PICC line with erythema and\n induration\n REASON FOR THIS EXAMINATION:\n please evaluate for RUE DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT seen in the right upper extremity. Right basilic PICC in\n place.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-25 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1063511, "text": " 6:23 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: power picc for CTA\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with dm1, q of PE\n REASON FOR THIS EXAMINATION:\n power picc for CTA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 40 year-old woman with existing PICC line via right arm\n who cannot travel to fluoroscopy because of her clinical status. Request is\n made for exchange of existing catheter with Power PICC for contrast injection.\n\n FELLOWS: and .\n\n RESIDENT: , MD\n\n STAFF RADIOLOGISTS: Dr. who supervised the procedure.\n\n SEDATION: Per ICU team.\n\n PROCEDURE AND FINDINGS: The right upper arm and existing catheter were\n prepped and draped in the usual sterile fashion. An 0.018 wire was passed\n through the existing catheter and the catheter was removed. A new 5 French\n double-lumen Vaxcel PICC line was placed over the wire at the appropriate\n length. The old wire was attempted to be removed but this proved to be\n difficult. Subsequently the existing catheter was removed and a new PICC line\n was placed. Again the old wire could not be removed. At this time, a new 5\n French peel-away sheath was placed over the wire. The wire was removed and\n replaced with an 0.018 Glidewire. A new 5 French double-lumen Vaxcel Power\n PICC line was placed over the wire. The wire was now removed easily. The\n sheath was peeled away. A sterile dressing was applied.\n\n IMPRESSION: Placement of 5 French double-lumen Power PICC line over wire at\n the bedside without fluoroscopic aid. The patient will get a chest x-ray to\n confirm tip position.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2105-04-02 00:00:00.000", "description": "Report", "row_id": 222157, "text": "Sinus rhythm. Possible anteroseptal myocardial infarction. Diffuse\nnon-diagnostic repolarization abnormalities. Compared to the previous tracing\nof multiple abnormalities as previously noted persist without major\nchange.\n\n" }, { "category": "ECG", "chartdate": "2105-03-30 00:00:00.000", "description": "Report", "row_id": 222158, "text": "Sinus rhythm. Non-specific ST-T wave abnormalities in the limb leads. Delayed\nprecordial R wave transition consistent with prior anterior infarction.\nCompared to the previous tracing of the rate has slowed. There is\nvaration in precordial lead placement. No diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2105-03-27 00:00:00.000", "description": "Report", "row_id": 222159, "text": "Sinus tachycardia. There is a late transition with tiny R waves in the\nanterior leads consistent with possible prior anterior myocardial infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing there is no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2105-04-04 00:00:00.000", "description": "Report", "row_id": 222156, "text": "Sinus rhythm. Poor R wave progression which is non-diagnostic. Inferolateral\nST-T wave changes which are non-specific. Compared to the previous tracing\nof there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2105-03-26 00:00:00.000", "description": "Report", "row_id": 222386, "text": "Sinus rhythm. Compared to the previous tracing the heart rate is somewhat\nreduced. Otherwise, no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2105-03-25 00:00:00.000", "description": "Report", "row_id": 222387, "text": "Sinus tachycardia. Borderline left axis deviation. Possible left anterior\nfascicular block. Anteroseptal myocardial infarction of indeterminate age.\nCompared to the previous tracing of left bundle-branch block pattern\nis no longer present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2105-03-24 00:00:00.000", "description": "Report", "row_id": 222388, "text": "Sinus tachycardia\nIntraventricular conduction delay\nLeft bundle branch block\nSince previous tracing of , QRS interval is wider\n\n" }, { "category": "ECG", "chartdate": "2105-03-23 00:00:00.000", "description": "Report", "row_id": 222389, "text": "Sinus tachycardia. Since the previous tracing T waves are again more\nprominent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2105-03-22 00:00:00.000", "description": "Report", "row_id": 222390, "text": "Sinus tachycardia. Since the previous tracing the QRS complex is narrower\nand T wave amplitudes are less. Consider resolution of hyperkalemia.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2105-03-20 00:00:00.000", "description": "Report", "row_id": 222391, "text": "Sinus tachycardia. Intraventricular conduction delay of left bundle-branch\nblock type. Consider left ventricular hypertrophy. ST-T wave abnormalities.\nSince the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2105-03-17 00:00:00.000", "description": "Report", "row_id": 222392, "text": "Sinus tachycardia\nLate R wave progression\nPossible left ventricular hypertrophy\nInferior/lateral T wave changes are probably due to ventricular hypertrophy\nSince previous tracing of , the heart rate is faster\n\n" }, { "category": "ECG", "chartdate": "2105-03-14 00:00:00.000", "description": "Report", "row_id": 222393, "text": "Sinus rhythm. Left atrial enlargement. Prior anteroseptal myocardial\ninfarction. Compared to the previous tracing of the previously\nmentioned abnormalities persist without diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2105-03-12 00:00:00.000", "description": "Report", "row_id": 222394, "text": "Sinus rhythm. The previously mentioned abnormalities recorded on \npersist without diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2105-03-11 00:00:00.000", "description": "Report", "row_id": 222395, "text": "Sinus rhythm. Intraventricular conduction delay. Left ventricular\nhypertrophy. Probable prior anterior myocardial infarction. Compared to the\nprevious tracing of no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2105-03-11 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1060861, "text": " 7:50 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for retained stone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with RUQ pain. Is s/p chole. +F, N/V/D\n REASON FOR THIS EXAMINATION:\n eval for retained stone\n ______________________________________________________________________________\n WET READ: JRCi WED 8:23 PM\n No duct dilitation. No findings to explain pain\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver and gallbladder ultrasound.\n\n INDICATION: Right upper quadrant pain.\n\n COMPARISONS: None available.\n\n FINDINGS: Liver displays normal echogenic pattern and architecture without\n focal mass lesion identified. Patient is status post cholecystectomy. There\n is no intra- or extra-hepatic biliary ductal dilatation with the common duct\n measuring 6 mm (may be normal in a post-cholecystectomy patient). The main\n portal vein is patent with normal hepatopetal flow. No right upper quadrant\n ascites is present. The right kidney appears unremarkable without\n hydronephrosis. The pancreas is not well evaluated given overlying bowel gas.\n\n IMPRESSION: No findings to explain patient's pain. S/p cholecystectomy\n without evidence of retained stone.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2105-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1061754, "text": ", W. MED FA2 3:24 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please check PICC tip reposition attempted\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n please check PICC tip reposition attempted\n ______________________________________________________________________________\n PFI REPORT\n Right-sided PICC remains malpositioned with tip coiled within the left\n brachiocephalic vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1061753, "text": " 3:24 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please check PICC tip reposition attempted\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n please check PICC tip reposition attempted\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb MON 7:17 PM\n Right-sided PICC remains malpositioned with tip coiled within the left\n brachiocephalic vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman after PICC placement, now re-positioned.\n\n COMPARISON: , at 13:58.\n\n AP PORTABLE CHEST: The right-sided PICC remains malpositioned with tip now\n coiled within the left brachiocephalic vein. The remainder of the radiograph\n is unchanged. No airspace consolidation or pneumothorax.\n\n Dr. discussed the findings with IV therapy .\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-11 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1060871, "text": " 9:15 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for appy\n Field of view: 46\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with abd pain, tender to palp\n REASON FOR THIS EXAMINATION:\n eval for appy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg WED 10:41 PM\n no appy, diverticulitis, or bowel obstruction.\n 13mm ground glass nodule in the right lung base, which has been stable since\n . continued follow up is recommended as Bronchoalveolar cell\n carcinoma is not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female with abdominal pain and tenderness to\n palpation. Evaluate for appendicitis.\n\n COMPARISON: CT.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the abdomen and pelvis\n from the lung bases to the pubic symphysis. Multiplanar reformatted images\n were obtained.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Atelectasis in the dependent\n portions of the lungs is mild. A 13-mm ground-glass nodule is identified in\n the right lower lobe (2:6) which is unchanged from CT dated . Continued followup is recommended as bronchioalveolar cell carcinoma is\n not excluded. Within the limitations of a non-contrast exam, no focal hepatic\n lesion is identified. The gallbladder has been removed. There is no intra-\n or extra-hepatic biliary dilatation. The pancreas shows extensive fatty\n atrophy. The spleen, adrenal glands, and kidneys are unremarkable. The\n intra-abdominal loops of large and small bowel are normal in caliber. The\n appendix is normal. The abdominal aorta is normal in caliber. Aortic\n atherosclerotic calcification is mild to moderate. A caval filter is\n identified in an infrarenal position. A small hiatal hernia is present. There\n is no free air, free fluid, or lymphadenopathy.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid colon, and\n bladder are unremarkable. Lobulated contour of the uterus may relate to\n fibroids. There is no free fluid or lymphadenopathy.\n\n BONE WINDOWS: There are no lesions suspicious for osseous metastases.\n Degenerative changes are noted at the lower lumbar spine. Posterior\n osteophytes and posterior disc bulge at L5-S1 result in moderate spinal\n stenosis. Note is made of diastasis of the rectus muscle. Note is made of a\n 4.3 x 3.3-cm intramuscular lipoma along the right hip. Multifocal areas of\n stranding in the soft tissues of the anterior pelvic and abdominal wall may\n relate to medication injection.\n\n (Over)\n\n 9:15 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for appy\n Field of view: 46\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. No evidence of appendicitis, diverticulitis, bowel obstruction, or intra-\n abdominal abscess.\n 2. 13-mm ground-glass nodule in the right lung base which has been stable\n since . Continued followup in six months is recommended as\n bronchioalveolar carcinoma is not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1061721, "text": " 1:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check PICC tip right brachial 44 cm\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n please check PICC tip right brachial 44 cm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb MON 5:42 PM\n New right PICC malpositioned with tip in the left subclavian vein. \n _____ of IV therapy on \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman after PICC placement.\n\n COMPARISON: .\n\n AP PORTABLE CHEST: The new right PICC is malpositioned with termination in\n the left subclavian vein. There is no pneumothorax. Heart size is top normal\n but unchanged. The lungs are clear. No pleural effusion.\n\n IMPRESSION: New right PICC is malpositioned with termination in the left\n subclavian vein.\n\n Dr. discussed the findings with the of IV\n therapy on .\n\n" }, { "category": "Radiology", "chartdate": "2105-03-17 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1061893, "text": " 9:42 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please reposition PICC crosses chest attempted repo at beds\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n please reposition PICC crosses chest attempted repo at bedside unsuccessfully\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMPd TUE 11:25 AM\n Existing PICC line repositioned, now with tip in the SVC. The catheter is\n ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 40-year-old woman with bedside placement of PICC line,\n which terminates in the axillary region. Request is made for repositioning\n versus replacement.\n\n FELLOW: Dr. .\n\n STAFF RADIOLOGIST: Dr. who supervised the procedure.\n\n ANESTHESIA: None.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and\n placed supine on the imaging table. The right upper arm and the existing\n catheter were prepped and draped in the usual sterile fashion. A scout image\n revealed the tip of the catheter in the right axillary region. A V18 wire was\n used to access one of the ports and advanced into the SVC using flouroscopic\n guidance. The PICC line was then advanced over the wire into the SVC. The\n wire was removed. Both ports flushed and aspirated easily. A sterile dressing\n was applied. There were no immediate complications.\n\n IMPRESSION: Repositioning of existing catheter in the right axillary region,\n now with tip in the SVC. The PICC line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-17 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1061894, "text": ", W. MED FA2 9:42 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please reposition PICC crosses chest attempted repo at beds\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n please reposition PICC crosses chest attempted repo at bedside unsuccessfully\n ______________________________________________________________________________\n PFI REPORT\n Existing PICC line repositioned, now with tip in the SVC. The catheter is\n ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-16 00:00:00.000", "description": "RENAL U.S.", "row_id": 1061667, "text": " 10:24 AM\n RENAL U.S. Clip # \n Reason: please eval for obstruction, hydronephrosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with acute renal failure, urinary retention\n REASON FOR THIS EXAMINATION:\n please eval for obstruction, hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute renal failure and urinary retention.\n\n COMPARISON: Comparison is made to a CT study done on .\n\n TECHNIQUE: Renal ultrasound.\n\n FINDINGS: The kidneys are normal in echotexture bilaterally and there is no\n hydronephrosis or nephrolithiasis. The left kidney measures 11.9 cm and is\n slightly lobular in contour, unchanged from the previous CT study. The right\n kidney measures 11.9 cm. The bladder is unremarkable.\n\n IMPRESSION:\n Grossly normal renal ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1061722, "text": ", W. MED FA2 1:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check PICC tip right brachial 44 cm\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n please check PICC tip right brachial 44 cm\n ______________________________________________________________________________\n PFI REPORT\n New right PICC malpositioned with tip in the left subclavian vein. \n _____ of IV therapy on \n\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660745, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Events at 2/19: Pt got 1 unit blood this morning for hct of 20 and it\n went upto 23.1. Heparin gtt turn it off temporarly for fem sheath\n removal at 1815,IR will come back after one hr for sheath removal. Pt\n received 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1600.u/hr. Pt.remains a+ox3.\n No s/s of bleeding. Pt. received on NC 6L, sat 99%, no c/o of SOB, but\n still unable to lay flat.c/o pain on her both leg in sheath place. Pt\n always nauseous, but tolerates Po meds with ginger ail and ice cream.\n Action:\n IR decide to keep sheath, Heparin gtt restart at 1900, PTT was 48,\n increased per sliding scale.Medicated with dilaudid 0.25mg Q2hr prn\n pain. On pt had CTa of her chest abd and pelvis to r/o\n retroperitoneal bleed, that shown no evidence of RP bleed. Able to wean\n o2 to NC 4L with sat 96-97%\n Response:\n . Pt. hemodynamically stable. Given Dilaudid pRN for pain with some\n effect, last PTT 70, cont Heparin at 1750u/hr\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 11am Monitor for\n s/s of bleeding. Possible to IR for tPA/thrombectomy\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. cont on insulin gtt , pt\n on 1 units/hr.. C/O nausesa\n Action:\n BS been 100-130. Finger sticks checked Q1h..Given compazine\n PRN/Ativan prn. overnight BS down to 92, decreased to 0.5u/hr\n Response:\n Cont Insulin gtt. compazine with moderate effect. BS remains on low\n 100\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n Vanco level 21.4, changed to 750mg q12hr.\n Pt dropped HCT to 21 from 23, MD aware.\n" }, { "category": "Nursing", "chartdate": "2105-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660677, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Evwents: Pt got 1 unit blood this morning for hct of 20 and it went\n upto 23.1. Heparin gtt turn it off temporarly for fem sheath removal\n at 1815,IR will come back after one hr for sheath removal. Pt received\n 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1 300u/hr. Pt.remains a+o.\n No s/s of bleeding. Pt. high flow xygen 50% FIO2 C/O pain on\n her left leg. Pt always naseous.\n Action:\n Heparin gtt titrated ypto 1600 last PTT was 59.3 at 1500. Medicated\n with dilaudid 0.25mg Q3H prn pain. Cardiac enzymes cycled. Pt had CTa\n of her chest abd and pelvis\n Response:\n Next PTT to be drawn at 2245. Pt. hemodynamically stable. Given\n Dilaudid pRN for pain .\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 2245. Monitor for\n s/s of bleeding.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. Started on insulin gtt yesterday\n as she was hypoglycemic with poor glucose control. pt on 1\n units/hr.. C/O N/ V\n Action:\n BS been 100-130. Finger sticks checked Q1h.Pt still NPO.Given\n Lorazepam0.5 mg IV PRN\n Response:\n Cont Insulin gtt. Lorazepam with moderate effect.\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n" }, { "category": "Physician ", "chartdate": "2105-03-27 00:00:00.000", "description": "ICU Attending Addendum", "row_id": 660800, "text": "CRITICAL CARE STAFF ADDENDUM\n 10:50a\n I saw and examined Ms. with the ICU team and was physically\n present for key portions of the services provided. I agree with the ICU\n team note today, including the assessment and plan. I would\n add/emphasize that her hypoxemia has improved substantially. IR plans\n to remove sheaths today. No complaints except nausea. On exam she is\n now 97% on 4L. Very edematous. Lungs clear anteriorly. Abdomen is\n soft and nontender (improved today). Groin sites intact. Labs as in\n ICU team note, esp notable for Hct 21 and Cr 1.4.\n Assessment and Plan\n 40-year-old woman with\n Marked deep venous thrombosis, including IVC filter clot\n Hypoxemia\n improving substantially\n Probable aspiration pneumonia (vs. pulmonary edema, though\n doubt that this was the only etiology)\n Acute renal failure\n has improved substantially\n Obesity and probable OSA\n Contrast allergy\n Etiology of hypoxemia remains uncertain. CXR suggested pneumonia but\n improvement favors edema somewhat.. We will complete an 8-day course\n for HAP unless cx dictate otherwise. Since she has known DVT (and\n therefore will be anticoagulated), and RV is not dilated, we have held\n off on CTA, since she is at higher-than-average risk for\n contrast-induced ARF. CCT not done by radiology.\n Volume overload\n we will diurese with goal -1000 today. Give Lasix\n 40mg IV (good response) whenever UOP trails off.\n Diabetes\n transition to SQ insulin\n Nausea/Vomiting\n as per ICU team note\n DVT\n now off of TPA, on therapeutic heparin. Hold heparin for sheath\n pull.\n Anemia\n Etiology not clear\n no melena and negative CT imaging.\n Transfuse now since sheath pull planned today.\n Other issues as per ICU team note today. Potentially to floor this\n afternoon.\n" }, { "category": "Physician ", "chartdate": "2105-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660764, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 02:24 PM\n Events:\n - had L thigh pain, no obvious cause at this time\n - CT scan negative for RP bleed\n - CT chest not done\n - IR recommended leaving catheters in for one more day in case they\n would look again tomorrow and do more TPA treatment\n - given lasix to see if respiratory status improved, had good urine\n output, then was able to be weaned from facemask to 6L NC overnight\n - vanco level 21.4; changed to 750 mg dosing\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:42 PM\n Ciprofloxacin - 10:42 PM\n Aztreonam - 04:03 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 AM\n Furosemide (Lasix) - 06:15 PM\n Heparin Sodium - 11:13 PM\n Lorazepam (Ativan) - 03:03 AM\n Hydromorphone (Dilaudid) - 06:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (83 - 115) bpm\n BP: 118/48(65) {104/44(61) - 158/77(101)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,003 mL\n 1,047 mL\n PO:\n TF:\n IVF:\n 4,719 mL\n 1,047 mL\n Blood products:\n 284 mL\n Total out:\n 4,470 mL\n 770 mL\n Urine:\n 4,470 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 533 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding, no grey- or cullen\ns signs\n Extremities: Right: 2+, Left: 2+, no evidence of fem hematoma\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli,\n Labs / Radiology\n 297 K/uL\n 7.2 g/dL\n 95 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 21.0 %\n 9.0 K/uL\n [image002.jpg]\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n 09:54 AM\n 02:28 PM\n 04:32 AM\n WBC\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n 10.2\n 11.1\n 9.0\n Hct\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n 22.1\n 23.7\n 21.0\n Plt\n 371\n 375\n 313\n \n 313\n 297\n Cr\n 1.4\n 1.5\n 1.4\n TropT\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 14\n 95\n Other labs: PT / PTT / INR:15.7/70.4/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis: Patient is s/p TPA by IR with question of anaphylaxis\n manifested tachycardia and hypoxemia. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure vs possible\n aspiration PNA on CXR . Low suspicion for MI by history ruled out\n with serial enzymes. Stopped heparin ggt through fem catheters once\n power PICC placed.\n .\n #Hypoxemia: PE vs. pulmonary infarct vs. aspiration vs obsesity\n hypoventilation and derecruitment in setting of procedure and\n sedation. PE high-risk given clot burden and peri-procedure;\n aspiration/HAP given body habitus, leukocytosis and low grade fever;\n CHF less likely given unilateral findings on CXR, BNP.\n - currently on face mask, wean O2 as tolerated\n - will obtain induced sputum cx\n - vanc/ Aztreonam /cipro for HAP/aspiration\n - will perform non-contrast CT (investigate pulmonary infiltrate) and\n venogram (holding for now given ARF.\n .\n #Renal Failure: Baseline Cr 1.1. Likely pre-renal complicated by ATN\n from contrast nephropathy. Renal ultrasound without obstruction.\n - Renal following, recs no dye load at this time, holding off on\n venogram for now\n - when okay with renal, will give prehydration protocol - IVF's,\n mucomyst, bicarbonate pre-procedure\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis , H. Pylori neg.\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs and reglan for promotility.\n - continue dilaudid prn pain and ativan for nausea given allergy\n profile\n - Gastritis - treating with PPI daily\n .\n # Anemia: Concerning in the setting of heparin ggt and TPA\n administration and s/p multiple procedures.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - pan-scan CT , eval for femoral bleed and RP bleed\n .\n # CAD: Known non-obstructive CAD on recent cath. Normal recent ECHO and\n stress test. Given chest pain on presentation will cycle enzmes -> CEs\n negative. EKG with TWI in V1 and V2. Cardiology shown EKG, no ACS.\n On heparin ggt for thrombosis.\n - no aspirin given allergy\n - continue statin\n - will add BP meds as tolerated\n - obtained rpt EKG , resolving TWI\n .\n # DM1:, needs basal insulin. Poorly controlled even while NPO. Takes\n 100 units glargine qhs, HbA1C 10.8 , 7.9 \n - continue insulin gtt until tolerating PO, FS 100-150, checking FS Q1H\n - Diabetic diet\n .\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n #Hypertension: Has h/o HTN. Received one dose of hydralazine PM\n as low suspicion for MI, and beta-blockade in setting of PE may\n precipitate hypotension.\n - will add home regimen as BP tolerates\n .\n # treated UTI: Treated and resolved.\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet, lytes prn\n # Access: power PICC, 2 femoral sheaths pulled \n # PPx: heparin ggt for thrombosis, PPI, bowel regimen\n # Code: FULL\n # Dispo: pending above , currently on insulin ggt\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2105-03-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 660940, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Abd/pelvic CT\n neg for retroperitoneal bleed.\n Bil sheaths removed. Pt remains on heparin gtt. Oxygen has been weaned\n to 4L NC.\n Events\n Pt c/o left chest pain/pressure radiiating down left arm.\n Mildly tachycardic in 100s, BP 150s-`60, no SOB but O2 ^^ 6L. EKG\n unchanged, CPKs sent which are flat. NTG SL x 3 with no significant\n change in CP. Dilaudid .5 mg with relief of CP, ? shower of clots (PE).\n CXR done. No further CP O/N.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Taking PO fluids, no other intake. Blood sugars in low 100s. C/o nausea\n x 1, phenergan 6.25 given with good effect.\n Action:\n No lantus given last evening per team as pt is still NPO d/t nausea. No\n SS insulin needed.\n Response:\n Blood sugars in good control\n Plan:\n Monitor blood sugars, pt is still not her home regime of lantus d/t\n poor PO intake.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o bil leg pain , L>R. Pt crying, stated she didn\nt want to take\n pain meds .\n Action:\n Emotional support given, explained need to keep pain under control.\n Dilaudid .25mg given\n Response:\n Pt reports relief and has been sleeping all night.\n Plan:\n Emotional support, assess and medicate for pain.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Bil LE edema +8. Dopplerable pulses. Feet elevated on pillows for\n comfort. Heparin gtt @ 1750 U/hr. Bil groin sites CD&I.\n Action:\n PTT in theraprutic range. Lasix 40 mg this AM for LE edema.\n Response:\n Diuresing , pt is 1500cc neg @ midnite, still with neg fluid balance so\n far today.\n Plan:\n Heparin gtt for DVT. Diurese prn.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n Admission weight:\n 125 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: CAD, CHF, Hypertension\n Additional history: Protein C deficiency\n Surgery / Procedure and date: s/pIVC filter \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:61\n Temperature:\n 96.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 135 mL\n 24h total out:\n 940 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:52 PM\n Potassium:\n 3.8 mEq/L\n 05:52 PM\n Chloride:\n 101 mEq/L\n 05:52 PM\n CO2:\n 28 mEq/L\n 05:52 PM\n BUN:\n 22 mg/dL\n 05:52 PM\n Creatinine:\n 1.3 mg/dL\n 05:52 PM\n Glucose:\n 150 mg/dL\n 05:52 PM\n Hematocrit:\n 22.9 %\n 03:20 AM\n Finger Stick Glucose:\n 124\n 03:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n ------ Protected Section ------\n --Pt is positive for c-Diff.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:53 ------\n" }, { "category": "Nursing", "chartdate": "2105-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660941, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Abd/pelvic CT\n neg for retroperitoneal bleed.\n Bil sheaths removed. Pt remains on heparin gtt. Oxygen has been weaned\n to 4L NC.\n Events\n Pt c/o left chest pain/pressure radiiating down left arm.\n Mildly tachycardic in 100s, BP 150s-`60, no SOB but O2 ^^ 6L. EKG\n unchanged, CPKs sent which are flat. NTG SL x 3 with no significant\n change in CP. Dilaudid .5 mg with relief of CP, ? shower of clots (PE).\n CXR done. No further CP O/N.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Taking PO fluids, no other intake. Blood sugars in low 100s. C/o nausea\n x 1, phenergan 6.25 given with good effect.\n Action:\n No lantus given last evening per team as pt is still NPO d/t nausea. No\n SS insulin needed.\n Response:\n Blood sugars in good control\n Plan:\n Monitor blood sugars, pt is still not her home regime of lantus d/t\n poor PO intake.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o bil leg pain , L>R. Pt crying, stated she didn\nt want to take\n pain meds .\n Action:\n Emotional support given, explained need to keep pain under control.\n Dilaudid .25mg given\n Response:\n Pt reports relief and has been sleeping all night.\n Plan:\n Emotional support, assess and medicate for pain.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Bil LE edema +8. Dopplerable pulses. Feet elevated on pillows for\n comfort. Heparin gtt @ 1750 U/hr. Bil groin sites CD&I.\n Action:\n PTT in theraprutic range. Lasix 40 mg this AM for LE edema.\n Response:\n Diuresing , pt is 1500cc neg @ midnite, still with neg fluid balance so\n far today.\n Plan:\n Heparin gtt for DVT. Diurese prn.\n ------ Protected Section ------\n Pt is positive for c-Diff\n ------ Protected Section Addendum Entered By: , RN\n on: 05:54 ------\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660465, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites.\n Action:\n PO dilaudid 4mg\n Response:\n Pain tolerable per pt\n :\n Cont dilaudid 4mg PO q3hrs PRN\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n No change in gtt rate. Following coags/hct q3hrs.\n Response:\n @3am PTT 41.1/fib 218\n Plan:\n Cont heparin/tpa gtts. Pt to IR to complete prodedure. Draw coags/hct\n @6am.\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Nutrition", "chartdate": "2105-03-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 660858, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 40 y/o female s/p PE c/ IVC filter in place c/ large IVC thrombosis\n treated c/ TPA. Pt reporting decreased appetite, poor po intake and\n tolerance since admission . PTtnot willing to trial supplements \n intolerance of supplements in the past. She is going to trial clear\n liquids from dinner tonight WIll f/u po intake/tolerance. If pt\n remains c/ poor intake and/or intolerance, will need to consider\n alternative nutrition support. Please page c/ ?'s #\n" }, { "category": "Nursing", "chartdate": "2105-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660653, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Of note: Hct this am 20 (down from 23 last evening) Pt. ordered for 1U\n PRBCs to be given over 2 hours. Type and Cross sent to blood bank.\n Waiting for blood to be ready at this time.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1 300u/hr. Pt.remains a+o.\n No s/s of bleeding. Pt. recived high flow xygen 50% FIO2 C/O pain on\n her left leg. Pt always naseous.\n Action:\n Heparin gtt titrated ypto 1600 last PTT was 59.3 at 1500. Medicated\n with dilaudid 0.25mg Q3H prn pain. Cardiac enzymes cycled. Pt had CTa\n of her chest abd and pelvis\n Response:\n Next PTT to be drawn at 2245. Pt. hemodynamically stable. Given\n Dilaudid pRN for pain .\n Plan:\n . Cont Heparin gtt goal is 50-70,Next PTT due at 2245. Monitor for\n s/s of bleeding.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. Started on insulin gtt yesterday\n as she was hypoglycemic with poor glucose control. Received on gtt at\n 14u/hr. Throughout shift, blood sugars trending down. Gtt titrated per\n insulin protocol.\n Action:\n Insulin gtt titrated to maintain fasting sugars between 100 to 150.\n Finger sticks checked Q1h\n Response:\n Blood sugars between 100 and 150 throughout shift with insulin titrated\n down to 1u/hr.\n Plan:\n Continue to check sugars Q1h. Titrate insulin gtt according to\n protocol.\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660721, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Events at 2/19: Pt got 1 unit blood this morning for hct of 20 and it\n went upto 23.1. Heparin gtt turn it off temporarly for fem sheath\n removal at 1815,IR will come back after one hr for sheath removal. Pt\n received 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1600.u/hr. Pt.remains a+ox3.\n No s/s of bleeding. Pt. received on NC 6L, sat 99%, no c/o of SOB, but\n still unable to lay flat.c/o pain on her both leg in sheath place. Pt\n always nauseous, but tolerates Po meds with ginger ail and ice cream.\n Action:\n IR decide to keep sheath, Heparin gtt restart at 1900, PTT was 48,\n increased per sliding scale.Medicated with dilaudid 0.25mg Q2hr prn\n pain. On pt had CTa of her chest abd and pelvis to r/o\n retroperitoneal bleed, that shown no evidence of RP bleed. Able to wean\n o2 to NC 4L with sat 96-97%\n Response:\n . Pt. hemodynamically stable. Given Dilaudid pRN for pain with some\n effect\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 11am Monitor for\n s/s of bleeding. Possible to IR for tPA/trombectomy\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. cont on insulin gtt , pt\n on 1 units/hr.. C/O nausesa\n Action:\n BS been 100-130. Finger sticks checked Q1h..Given compazine\n PRN/Ativan prn. overnight BS down to 92, decreased to 0.5u/hr\n Response:\n Cont Insulin gtt. compazine with moderate effect. BS remains on low\n 100\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n Vanco level 21.4, changed to 750mg q12hr.\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660722, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Events at 2/19: Pt got 1 unit blood this morning for hct of 20 and it\n went upto 23.1. Heparin gtt turn it off temporarly for fem sheath\n removal at 1815,IR will come back after one hr for sheath removal. Pt\n received 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1600.u/hr. Pt.remains a+ox3.\n No s/s of bleeding. Pt. received on NC 6L, sat 99%, no c/o of SOB, but\n still unable to lay flat.c/o pain on her both leg in sheath place. Pt\n always nauseous, but tolerates Po meds with ginger ail and ice cream.\n Action:\n IR decide to keep sheath, Heparin gtt restart at 1900, PTT was 48,\n increased per sliding scale.Medicated with dilaudid 0.25mg Q2hr prn\n pain. On pt had CTa of her chest abd and pelvis to r/o\n retroperitoneal bleed, that shown no evidence of RP bleed. Able to wean\n o2 to NC 4L with sat 96-97%\n Response:\n . Pt. hemodynamically stable. Given Dilaudid pRN for pain with some\n effect\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 11am Monitor for\n s/s of bleeding. Possible to IR for tPA/thrombectomy\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. cont on insulin gtt , pt\n on 1 units/hr.. C/O nausesa\n Action:\n BS been 100-130. Finger sticks checked Q1h..Given compazine\n PRN/Ativan prn. overnight BS down to 92, decreased to 0.5u/hr\n Response:\n Cont Insulin gtt. compazine with moderate effect. BS remains on low\n 100\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n Vanco level 21.4, changed to 750mg q12hr.\n" }, { "category": "Physician ", "chartdate": "2105-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660827, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 02:24 PM\n Events:\n - had L thigh pain, no obvious cause at this time\n - CT scan negative for RP bleed\n - CT chest not done\n - IR recommended leaving catheters in for one more day in case they\n would look again tomorrow and do more TPA treatment\n - given lasix to see if respiratory status improved, had good urine\n output, then was able to be weaned from facemask to 6L NC overnight\n - vanco level 21.4; changed to 750 mg dosing\n - patient developed loose bowel movements\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:42 PM\n Ciprofloxacin - 10:42 PM\n Aztreonam - 04:03 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,750 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 AM\n Furosemide (Lasix) - 06:15 PM\n Heparin Sodium - 11:13 PM\n Lorazepam (Ativan) - 03:03 AM\n Hydromorphone (Dilaudid) - 06:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.4\n HR: 83 (83 - 115) bpm\n BP: 118/48(65) {104/44(61) - 158/77(101)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,003 mL\n 1,047 mL\n PO:\n TF:\n IVF:\n 4,719 mL\n 1,047 mL\n Blood products:\n 284 mL\n Total out:\n 4,470 mL\n 770 mL\n Urine:\n 4,470 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 533 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: pulses nl throughout\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding, no grey- or cullen\ns signs\n Extremities: Right: 2+, Left: 2+, no evidence of fem hematoma\n Neurologic: Attentive, Follows commands, Responds to: Verbal stimuli,\n Labs / Radiology\n 297 K/uL\n 7.2 g/dL\n 95 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 21.0 %\n 9.0 K/uL\n [image002.jpg]\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n 09:54 AM\n 02:28 PM\n 04:32 AM\n WBC\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n 10.2\n 11.1\n 9.0\n Hct\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n 22.1\n 23.7\n 21.0\n Plt\n 371\n 375\n 313\n \n 313\n 297\n Cr\n 1.4\n 1.5\n 1.4\n TropT\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 14\n 95\n Other labs: PT / PTT / INR:15.7/70.4/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis: Patient is s/p TPA by IR with question of anaphylaxis\n manifested tachycardia and hypoxemia. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure vs possible\n aspiration PNA on CXR . Low suspicion for MI by history ruled out\n with serial enzymes. Stopped heparin ggt through fem catheters once\n power PICC placed. IR pulled fem cathethers on after they\n determined patient would not benefit from additional TPA. Pan scan was\n done which did not show any hematoma or bleed.\n - Hct\n - - will perform venogram (holding for now given ARF\n .\n #Hypoxemia: PE vs. pulmonary infarct vs. aspiration vs obsesity\n hypoventilation and derecruitment in setting of procedure and\n sedation. PE high-risk given clot burden and peri-procedure;\n aspiration/HAP given body habitus, leukocytosis and low grade fever;\n CHF less likely given unilateral findings on CXR, BNP. O2 requirements\n weaned to NC on . Appears to be worsen in the setting of volume\n overload and pulmonary edema.\n - follow up cx\n - vanc/ Aztreonam /cipro for HAP/aspiration\n - check vanc level tonight\n .\n # Vol overload\n patient has 10L positive since admission and diffuse\n edema and pulmonary edema. Patient takes Lasix 80mg PO daily as\n outpatient and responded well to Lasix 40mg IV X1 overnight .\n - giving Lasix 40mg IV BID\n #Renal Failure: Baseline Cr 1.1. Likely pre-renal complicated by ATN\n from contrast nephropathy. Renal ultrasound without obstruction.\n - Renal following, recs no dye load at this time, holding off on\n venogram for now\n - when okay with renal, will give prehydration protocol - IVF's,\n mucomyst, bicarbonate pre-procedure\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis , H. Pylori neg.\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs and reglan for promotility.\n - continue dilaudid prn pain and ativan for nausea given allergy\n profile\n - Gastritis - treating with PPI daily\n .\n # Anemia: Concerning in the setting of heparin ggt and TPA\n administration and s/p multiple procedures. Pan scan negative, no fem\n hematoma or RP bleed.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - since HCt 21 and possibility of bleeding and dropping Hct,\n transfusing 1u PRBC now\n .\n # CAD: Known non-obstructive CAD on recent cath. Normal recent ECHO and\n stress test. Given chest pain on presentation will cycle enzmes -> CEs\n negative. EKG with TWI in V1 and V2. Cardiology shown EKG, no ACS.\n On heparin ggt for thrombosis. EKG changes resolved the following day\n and patient did not complain of further chest pain.\n - no aspirin given allergy\n - continue statin\n - will add BP meds as tolerated\n .\n # DM1:, needs basal insulin. Poorly controlled even while NPO. Takes\n 100 units glargine qhs, HbA1C 10.8 , 7.9 \n Sugars continued to be in 100-150 range while on insulin ggt and\n .\n # Diarrhea\n in the setting of prolonged hospitalization stay\n - stopping bowel regimen and sending c diff, no precautions\n since low prob\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n #Hypertension: Has h/o HTN. Received one dose of hydralazine PM\n as low suspicion for MI, and beta-blockade in setting of PE may\n precipitate hypotension.\n - will add home regimen as BP tolerates\n .\n # treated UTI: Treated and resolved.\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet, lytes prn\n # Access: power PICC, 2 femoral sheaths pulled (atropine at\n bedside during pull in case of vagal response)\n # PPx: heparin ggt for thrombosis, PPI, bowel regimen\n # Code: FULL\n # Dispo: called out\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2105-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660917, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Abd/pelvic CT\n neg for retroperitoneal bleed.\n Bil sheaths removed. Pt remains on heparin gtt. Oxygen has been weaned\n to 4L NC.\n Events\n Pt c/o left chest pain/pressure radiiating down left arm.\n Mildly tachycardic in 100s, BP 150s-`60, no SOB but O2 ^^ 6L. EKG\n unchanged, CPKs sent which are flat. NTG SL x 3 with no significant\n change in CP. Dilaudid .5 mg with relief of CP, ? shower of clots (PE).\n CXR done. No further CP O/N.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Taking PO fluids, no other intake. Blood sugars in low 100s. C/o nausea\n x 1, phenergan 6.25 given with good effect.\n Action:\n No lantus given last evening per team as pt is still NPO d/t nausea. No\n SS insulin needed.\n Response:\n Blood sugars in good control\n Plan:\n Monitor blood sugars, pt is still not her home regime of lantus d/t\n poor PO intake.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o bil leg pain , L>R. Pt crying, stated she didn\nt want to take\n pain meds .\n Action:\n Emotional support given, explained need to keep pain under control.\n Dilaudid .25mg given\n Response:\n Pt reports relief and has been sleeping all night.\n Plan:\n Emotional support, assess and medicate for pain.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Bil LE edema +8. Dopplerable pulses. Feet elevated on pillows for\n comfort. Heparin gtt @ 1750 U/hr. Bil groin sites CD&I.\n Action:\n PTT in theraprutic range. Lasix 40 mg this AM for LE edema.\n Response:\n Diuresing , pt is 1500cc neg @ midnite, still with neg fluid balance so\n far today.\n Plan:\n Heparin gtt for DVT. Diurese prn.\n" }, { "category": "Nursing", "chartdate": "2105-03-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 660919, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Abd/pelvic CT\n neg for retroperitoneal bleed.\n Bil sheaths removed. Pt remains on heparin gtt. Oxygen has been weaned\n to 4L NC.\n Events\n Pt c/o left chest pain/pressure radiiating down left arm.\n Mildly tachycardic in 100s, BP 150s-`60, no SOB but O2 ^^ 6L. EKG\n unchanged, CPKs sent which are flat. NTG SL x 3 with no significant\n change in CP. Dilaudid .5 mg with relief of CP, ? shower of clots (PE).\n CXR done. No further CP O/N.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Taking PO fluids, no other intake. Blood sugars in low 100s. C/o nausea\n x 1, phenergan 6.25 given with good effect.\n Action:\n No lantus given last evening per team as pt is still NPO d/t nausea. No\n SS insulin needed.\n Response:\n Blood sugars in good control\n Plan:\n Monitor blood sugars, pt is still not her home regime of lantus d/t\n poor PO intake.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o bil leg pain , L>R. Pt crying, stated she didn\nt want to take\n pain meds .\n Action:\n Emotional support given, explained need to keep pain under control.\n Dilaudid .25mg given\n Response:\n Pt reports relief and has been sleeping all night.\n Plan:\n Emotional support, assess and medicate for pain.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Bil LE edema +8. Dopplerable pulses. Feet elevated on pillows for\n comfort. Heparin gtt @ 1750 U/hr. Bil groin sites CD&I.\n Action:\n PTT in theraprutic range. Lasix 40 mg this AM for LE edema.\n Response:\n Diuresing , pt is 1500cc neg @ midnite, still with neg fluid balance so\n far today.\n Plan:\n Heparin gtt for DVT. Diurese prn.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n Admission weight:\n 125 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: CAD, CHF, Hypertension\n Additional history: Protein C deficiency\n Surgery / Procedure and date: s/pIVC filter \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:61\n Temperature:\n 96.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 135 mL\n 24h total out:\n 940 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:52 PM\n Potassium:\n 3.8 mEq/L\n 05:52 PM\n Chloride:\n 101 mEq/L\n 05:52 PM\n CO2:\n 28 mEq/L\n 05:52 PM\n BUN:\n 22 mg/dL\n 05:52 PM\n Creatinine:\n 1.3 mg/dL\n 05:52 PM\n Glucose:\n 150 mg/dL\n 05:52 PM\n Hematocrit:\n 22.9 %\n 03:20 AM\n Finger Stick Glucose:\n 124\n 03:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660702, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Events at 2/19: Pt got 1 unit blood this morning for hct of 20 and it\n went upto 23.1. Heparin gtt turn it off temporarly for fem sheath\n removal at 1815,IR will come back after one hr for sheath removal. Pt\n received 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1600.u/hr. Pt.remains a+ox3.\n No s/s of bleeding. Pt. received on NC 6L, sat 99%, no c/o of SOB, but\n still unable to lay flat.c/o pain on her both leg in sheath place. Pt\n always nauseous, but tolerates Po meds with ginger ail and ice cream.\n Action:\n IR decide to keep sheath, Heparin gtt restart at 1900, PTT was 48,\n increased per sliding scale.Medicated with dilaudid 0.25mg Q2hr prn\n pain. Pt had CTa of her chest abd and pelvis\n Response:\n . Pt. hemodynamically stable. Given Dilaudid pRN for pain with some\n effect\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 11am Monitor for\n s/s of bleeding. Possible to IR\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. cont on insulin gtt , pt\n on 1 units/hr.. C/O nausesa\n Action:\n BS been 100-130. Finger sticks checked Q1h..Given compazine PRN\n overnight BS dwont to 92, decreased to 0.5u/hr\n Response:\n Cont Insulin gtt. compazine with moderate effect. BS remains on low\n 100\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n Vanco level 21.4, changed to 750mg q12hr.\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660703, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Events at 2/19: Pt got 1 unit blood this morning for hct of 20 and it\n went upto 23.1. Heparin gtt turn it off temporarly for fem sheath\n removal at 1815,IR will come back after one hr for sheath removal. Pt\n received 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1600.u/hr. Pt.remains a+ox3.\n No s/s of bleeding. Pt. received on NC 6L, sat 99%, no c/o of SOB, but\n still unable to lay flat.c/o pain on her both leg in sheath place. Pt\n always nauseous, but tolerates Po meds with ginger ail and ice cream.\n Action:\n IR decide to keep sheath, Heparin gtt restart at 1900, PTT was 48,\n increased per sliding scale.Medicated with dilaudid 0.25mg Q2hr prn\n pain. On pt had CTa of her chest abd and pelvis to r/o\n retroperitoneal bleed, that shown no evidence of RP bleed.\n Response:\n . Pt. hemodynamically stable. Given Dilaudid pRN for pain with some\n effect\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 11am Monitor for\n s/s of bleeding. Possible to IR\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. cont on insulin gtt , pt\n on 1 units/hr.. C/O nausesa\n Action:\n BS been 100-130. Finger sticks checked Q1h..Given compazine PRN\n overnight BS dwont to 92, decreased to 0.5u/hr\n Response:\n Cont Insulin gtt. compazine with moderate effect. BS remains on low\n 100\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n Vanco level 21.4, changed to 750mg q12hr.\n" }, { "category": "Nursing", "chartdate": "2105-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660910, "text": "Events\n Pt c/o left chest pain/pressure radiiating down left arm.\n Mildly tachycardic in 100s, BP 150s-`60, no SOB but O2 ^^ 6L. EKG\n unchanged, CPKs sent which are flat. NTG SL x 3 with no significant\n change in CP. Dilaudid .5 mg with relief of CP, ? shower of clots (PE).\n CXR done. No further CP O/N.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660337, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660338, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites.\n Action:\n PO dilaudid 4mg\n Response:\n Pain tolerable per pt\n :\n Cont dilaudid 4mg PO q3hrs PRN\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n No change in gtt rate. Following coags/hct q3hrs.\n Response:\n PTT\n Plan:\n Cont heparin/tpa gtts. Pt to IR to complete prodedure.\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Physician ", "chartdate": "2105-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660380, "text": "Chief Complaint:\n 24 Hour Events:\n no acute events overnight\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 250 units/hour\n Other ICU medications:\n Hydralazine - 06:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 104 (96 - 118) bpm\n BP: 166/75(96) {125/60(77) - 185/92(112)} mmHg\n RR: 28 (20 - 28) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,924 mL\n 2,226 mL\n PO:\n TF:\n IVF:\n 1,924 mL\n 2,226 mL\n Blood products:\n Total out:\n 340 mL\n 610 mL\n Urine:\n 340 mL\n 510 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,584 mL\n 1,616 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 371 K/uL\n 8.7 g/dL\n 217 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 106 mEq/L\n 138 mEq/L\n 26.3 %\n 15.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n WBC\n 11.7\n 15.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n Plt\n 384\n 371\n Cr\n 1.5\n 1.4\n TropT\n 0.02\n 0.04\n Glucose\n 215\n 217\n Other labs: PT / PTT / INR:15.3/34.8/1.4, CK / CKMB /\n Troponin-T:175/3/0.04, Fibrinogen:249 mg/dL, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660384, "text": "Chief Complaint:\n 24 Hour Events:\n no acute events overnight\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 250 units/hour\n Other ICU medications:\n Hydralazine - 06:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 104 (96 - 118) bpm\n BP: 166/75(96) {125/60(77) - 185/92(112)} mmHg\n RR: 28 (20 - 28) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,924 mL\n 2,226 mL\n PO:\n TF:\n IVF:\n 1,924 mL\n 2,226 mL\n Blood products:\n Total out:\n 340 mL\n 610 mL\n Urine:\n 340 mL\n 510 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,584 mL\n 1,616 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 371 K/uL\n 8.7 g/dL\n 217 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 106 mEq/L\n 138 mEq/L\n 26.3 %\n 15.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n WBC\n 11.7\n 15.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n Plt\n 384\n 371\n Cr\n 1.5\n 1.4\n TropT\n 0.02\n 0.04\n Glucose\n 215\n 217\n Other labs: PT / PTT / INR:15.3/34.8/1.4, CK / CKMB /\n Troponin-T:175/3/0.04, Fibrinogen:249 mg/dL, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660386, "text": "Chief Complaint:\n 24 Hour Events:\n no acute events overnight\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 250 units/hour\n Other ICU medications:\n Hydralazine - 06:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 104 (96 - 118) bpm\n BP: 166/75(96) {125/60(77) - 185/92(112)} mmHg\n RR: 28 (20 - 28) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,924 mL\n 2,226 mL\n PO:\n TF:\n IVF:\n 1,924 mL\n 2,226 mL\n Blood products:\n Total out:\n 340 mL\n 610 mL\n Urine:\n 340 mL\n 510 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,584 mL\n 1,616 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 371 K/uL\n 8.7 g/dL\n 217 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 106 mEq/L\n 138 mEq/L\n 26.3 %\n 15.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n WBC\n 11.7\n 15.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n Plt\n 384\n 371\n Cr\n 1.5\n 1.4\n TropT\n 0.02\n 0.04\n Glucose\n 215\n 217\n Other labs: PT / PTT / INR:15.3/34.8/1.4, CK / CKMB /\n Troponin-T:175/3/0.04, Fibrinogen:249 mg/dL, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis and Post-procedure mgmt: s/p TPA by IR with question\n of anaphylaxis. Procedure complicated by tachycardia, hypoxemia.\n Transferred to ICU for monitoring. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure. No\n evidence for aspiration at this time. Low suspicion for MI by history\n but would rule out with serial enzymes. Lastly might represent CHF\n given e/o volume overload on exam and h/o diastolic dysfunction.\n - 0.5mg/hr TPA on each side for total of 1.0mg/hr\n - 250 units heparin gtt per hour for each sheeth (total 500)\n - no other heparin products to be given\n - Avoid blood draws, arterial sticks or arterial lines\n - frequent neuro checks q2 hours for stroke\n - Coags and fibrinogen q3 hours, h/h q6 hours\n - If fibrinogen < 150, decrease by and recheck in 1 hour.\n - If firbinogen < 100, stop TPA and call IR, can draw from sheaths as\n long as it is flushed with saline.\n - 40mg Prednisone 16, 8 and 2 hour pre-procedure - plan for 10am today\n - 150mg zantac 1 hour pre-procedure\n - 15mg PO benadryl 1 hour pre-procedure\n .\n #Hypoxemia: PE vs. aspiration vs. CHF vs obsesity hypoventilation and\n derecruitment in setting of procedure and sedation. Question of volume\n overload given h/o diastolic CHF and lying supine for procedure. CXR\n concerning for possible fluid overload, less likely aspiration. BNP\n only mildly elevated, r/o with CEs.\n - NRB and wean as tolerated.\n - c/s ABX for possible aspiration given O2 requirements (leukocytosis\n difficult to interpret given recent steroids\n will check diff)\n - autoset CPAP overnight\n .\n #Renal Failure: Baseline Cr 1.1. Team thought pre-renal complicated by\n slight ATN. Renal ultrasound without obstruction.\n - IVF's, mucomyst, bicarbonate pre-procedure\n - Continue hydration\n - renal ultrasound without obstruction\n .\n #Hypertension: Has h/o HTN. Received one dose of hydralazine PM\n as low suspicion for MI, and beta-blockade in setting of PE may\n precipitate hypotension.\n .\n #Tachycardia: Appears to be sinus tach by ECG. PE vs. pain vs.\n agitation.\n - Continue to follow\n - Management as above\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs for promotility. Will d/w GI re why\n not reglan or erythromycin.\n - continue promethazine and dilaudid prn\n - Gastritis - H. Pylori neg, treating with PPI daily\n .\n # UTI: Treated and resolved, follow Cr.\n .\n # Anemia: Continues to trend down and started on Fe replacement.\n Negative EGD. Will need to trend hematocrit on TPA and heparin.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - Pt unable to tolerate bowel prep now (nausea, renal failure), but if\n diarrhea or worsening anemia persists, will need colonoscopy\n .\n # CAD: Known nonobstructive CAD on recent cath. Normal recent ECHO and\n stress test. given chest pain on presentation will cycle enzmes -> CEs\n negative.\n - no aspirin given allergy\n - continue statin\n - continue holding BP meds\n .\n # Diabetes: Poorly controlled even while NPO. Takes 100 units glargine\n qhs\n - HbA1C 10.8 , 7.9 \n - Continue lantus 100 and HISS\n - Eating today so will restart standing humalog\n - Diabetic diet\n .\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n .\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet, no IVF, lytes prn\n # Access: PICC, 2 femoral sheaths\n # PPx: heparin IV infusion, TPA, no other heparin products at this\n time.\n # Code: presumed FULL\n # Dispo: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 660517, "text": "TITLE:\n Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Continued hypoxemia, essentially stable.\n Hypertension better controlled\n Says her dyspnea is improved\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 250 units/hour\n Other ICU medications:\n Hydralazine - 06:30 PM\n Other medications:\n heparin, TPA, NAC, prednisone @ 40, Reglan, iron, PPI, SQI, statin,\n Klonopin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 102 (96 - 118) bpm\n BP: 138/59(79) {125/59(77) - 185/92(112)} mmHg\n RR: 24 (20 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,924 mL\n 2,626 mL\n PO:\n TF:\n IVF:\n 1,924 mL\n 2,626 mL\n Blood products:\n Total out:\n 340 mL\n 790 mL\n Urine:\n 340 mL\n 690 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,584 mL\n 1,836 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), anterior exam; unable\n to examine posterior due to groin catheters\n Abdominal: Soft, Tender: continued discomfort with palpation\n Extremities: Right: 2+ edema, Left: 2+ edema\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 371 K/uL\n 217 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 106 mEq/L\n 138 mEq/L\n 26.3 %\n 15.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n WBC\n 11.7\n 15.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n Plt\n 384\n 371\n Cr\n 1.5\n 1.4\n TropT\n 0.02\n 0.04\n Glucose\n 215\n 217\n Other labs: PT / PTT / INR:15.3/34.8/1.4, CK / CKMB /\n Troponin-T:175/3/0.04, Differential-Neuts:89.3 %, Lymph:4.6 %, Mono:5.3\n %, Eos:0.6 %, Fibrinogen:249 mg/dL, Ca++:8.1 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.8 mg/dL\n CXR today shows increased right base opacity and left base\n consolidation\n Assessment and Plan\n 40-year-old woman with\n Marked deep venous thrombosis, including IVC filter clot\n Hypoxemia\n Acute renal failure\n improving\n Obesity and probable OSA\n Contrast allergy\n Etiology of hypoxemia is not totally clear. CXR suggests pneumonia; PE\n is in DDx. We will treat for HAP and check Cx. Since she has known\n DVT (and therefore will be anticoagulated), we will only pursue CTA of\n chest if RV is dilated, since she is at higher-than-average risk for\n contrast-induced ARF.\n Tachycardia may be hypovolemic, PE, or pericardial. Will check echo,\n EKG, and give fluid challenge. Depending on echo findings and fluid\n response, will consider trial of beta blockade given possibility of\n ACS. ASA/Plavix allergic. Will discuss with IR when we can convert to\n IV heparin\n Diabetes\n begin insulin gtt\n DVT\n will discuss with IR duration of TPA and further management\n Other issues as per ICU team note today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT: Boots(on local heparin and TPA)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660520, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites and\n right upper quadrant.\n Action:\n PO dilaudid 4mg as well dilaudid 0.25 mg given with some effect. While\n IR tried to change her reg PIVCC line to Power PICC lineshe c/o chest\n pain radiating to her back,done EKG( T inversion ? ),given\n Nitorglycerin .3 mg Sl x2 with some effect.Sent cardiac\n markers,consulting Cardiology\n Response:\n Cont have pain inspite of dilaudid.\n Plan:\n Dilaudid changed into IV 0.23 mg IV PRN and closely monitor for pain.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n PTT at 1600 33.4And Hct at 1600 23.5. IR came by and pulled out \n from sheath, stopped heparin and tpa ansd started on NS at 50cc/hr...\n Planning to do CTA as soon as possible\n Response:\n heparin gtt started through PICC line at 1000cc/hr.\n Plan:\n CTA to tule out PE? . Next set due at 0000 .\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660521, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites and\n right upper quadrant.\n Action:\n PO dilaudid 4mg as well dilaudid 0.25 mg given with some effect. While\n IR tried to change her reg PIVCC line to Power PICC lineshe c/o chest\n pain radiating to her back,done EKG( T inversion ? ),given\n Nitorglycerin .3 mg Sl x2 with some effect.Sent cardiac\n markers,consulting Cardiology\n Response:\n Cont have pain inspite of dilaudid.\n Plan:\n Dilaudid changed into IV 0.23 mg IV PRN and closely monitor for pain.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n PTT at 1600 33.4And Hct at 1600 23.5. IR came by and pulled out \n from sheath, stopped heparin and tpa ansd started on NS at 50cc/hr...\n Planning to do CTA as soon as possible\n Response:\n heparin gtt started through PICC line at 1000cc/hr.\n Plan:\n CTA to tule out PE? . Next set due at 0000 .\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660696, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Events at 2/19: Pt got 1 unit blood this morning for hct of 20 and it\n went upto 23.1. Heparin gtt turn it off temporarly for fem sheath\n removal at 1815,IR will come back after one hr for sheath removal. Pt\n received 40 mgLasix IV around 1815, goal ~1L.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Cont have R and L femoral catheters in place with NS at 50cc/hr\n running through each sheath to keep it open. +pedal pulses, bilat\n lower extremities warm and + 3 edema,swollen Dr . Dressings\n C/D/I. Pt. also received on heparin gtt at 1600.u/hr. Pt.remains a+ox3.\n No s/s of bleeding. Pt. received on NC 6L, sat 99%, no c/o of SOB, but\n still unable to lay flat.c/o pain on her both leg in sheath place. Pt\n always nauseous, but tolerates Po meds with ginger ail and ice cream.\n Action:\n IR decide to keep sheath, Heparin gtt restart at 1900, PTT was 48,\n increased per sliding scale.Medicated with dilaudid 0.25mg Q2hr prn\n pain. Pt had CTa of her chest abd and pelvis\n Response:\n . Pt. hemodynamically stable. Given Dilaudid pRN for pain with some\n effect\n Plan:\n . Cont Heparin gtt goal is 60-100 ,Next PTT due at 11am Monitor for\n s/s of bleeding. Possible to IR\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. cont on insulin gtt , pt\n on 1 units/hr.. C/O nausesa\n Action:\n BS been 100-130. Finger sticks checked Q1h..Given compazine PRN\n Response:\n Cont Insulin gtt. compazine with moderate effect.\n Plan:\n Cont Bs check Q1h and titrate Insulin gtt accordingly. .\n Vanco level 21.4, changed to 750mg q12hr.\n" }, { "category": "Nursing", "chartdate": "2105-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660899, "text": "EVENTS\nheparin switched of and sheaths removed by IR\nreceived x1uprbcs\n for hct at 21, received lasix total 80mgs to maintain U/O >\n 100cc/hr\ninsulin drip stopped longacting commenced with s/s\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Patient received on heparin drip with bilateral fem sheaths insitu,\n pedal pulses present feet warm/senastion\n Action:\n Heparin stopped as per instruction of IR and sheaths pulled\n Response:\n Groin stable, pedal pulses present no bleeding seen, warmth/sensation\n Plan:\n Heparin re-commenced at 1400hrs, for ptt at 2000hrs, after bedrest pt\n OOB to chair\n Pain control (acute pain, chronic pain)\n Assessment:\n Received with pain in both groins\n Action:\n Patient receiving dilaudid and ativan PRN patient required extra dose\n when sheaths removed\n Response:\n Iv dilaudid dose reduce pain but patient not painfree\n Plan:\n Continue to medicate and evaluate pain level\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received on insulin drip b/s @ 120-130, minimal diet\n Action:\n One dose of glargine 30units this am, will receive another dose again\n this eve covered with s/s q6, diet encoraged\n Response:\n b/s maintained at 150\n Plan:\n Follow b/s closely as patient is normally on higher doses at home,\n encourage po intake\n" }, { "category": "Nursing", "chartdate": "2105-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660318, "text": "40yo female PMH: of PE x2 in and 6/. s/pIVC filter \n maintained on coumadin, though noncompliant; DM, type I; CAD s/p NSTEMI\n per pt report; HTN; Protein C deficiency; ? h/o CHF, ECHO w/o\n LVH or sys dysfunction (EF>55%); Hyperlipidemia admitted to the floor\n on for RUQ pain EGD on revealed gastroparesis and\n erosive gastritis. Throughout her hospital course, she has been noted\n to have significant progressive lower extremity edema.\n pt sent to IR for thrombolysis/ectomy of IVC fliter. While in IR,\n after reciving angiojet pt, c/o sob, feeling like her\nthroat was\n closing\n. And desatted to the higjh 80%\ns. pt was given benadryl 50mg,\n placed on 100% non rebreather and her 02 sat quickly improved into the\n mid 90%\ns. pt non compliant w/ 02 mask switched to 6L n/c and\n transferred to the MICU for further management.\n Pt arrived in the MICU w/ TPA at 0.5mg/hr and Heparin 250 units/hr\n running through each sheath w/ plan to return to IR in the am to\n complete procedure. 02 sat 87-88% on 6L upon arrival to MICU, placed on\n 100% NRB with sats immediately improving to 95-99% b/p 170-192/100\n 10mg IV hydralazine given a/o. pt c/o pain and nausea, medicated w/ IV\n dilaudid and phenergan w/ some eff.\n Plan is to cont TPA and heparin overnight and return to IR for\n completion of procedure in the am.\n" }, { "category": "Physician ", "chartdate": "2105-03-24 00:00:00.000", "description": "ICU attending", "row_id": 660323, "text": "CRITICAL CARE STAFF\n 7p\n I saw and examined Ms. with Dr. , whose note reflects my\n input. She is a 40-year-old woman admitted to the ICU for IR-guided\n TPA infusion as well as acute hypoxemia. Her PMH is notable for\n diabetes, PE, IVC filter, ??protein C deficiency, and CAD who presented\n with abdominal symptoms. Evaluation suggested gastroparesis as the\n etiology. She then had an episode of hypotension as well as\n progressive edema. Evaluation revealed IVC thrombus. She went to IR\n today for possible thrombectomy / TPA infusion. Although\n pre-medicated, she had an episode of hypoxemia/tachycardia/throat\n tightness that was concerning for contrast reaction and the procedure\n was halted. On exam now she is comfortable. HR 110, BP 190/80, RR22,\n 100% on NRB. She is obese. Lungs have scant basilar crackles. Abdomen\n is soft but has discomfort with palpation. Extremities have edema.\n Groin catheter sites clean.\n CXR pending.\n EKG pending.\n Assessment and Plan\n 40-year-old woman with\n IVC thrombus receiving TPA\n Hypoxemia\n o ?contrast reaction or anaphylaxis\n o ?derecruitment (high pretest probability for OSA, supine\n position, conscious sedation)\n o ?aspiration\n o ?PE\n Renal failure\n Abdominal pain\n We will check CXR and EKG. If this was a contrast reaction, seems to\n have subsided at present. Continue present therapy with steroids and\n histamine blockade. Will continue TPA and heparin per IR; would favor\n systemic anticoagulation if acceptable. Will consider trial of PAP\n this evening, depending on how her oxygen requirement progresses.\n Likely back to IR tomorrow.\n Other issues as per Dr. \ns note.\n She is critically ill. 35 minutes\n" }, { "category": "Physician ", "chartdate": "2105-03-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 660326, "text": "Chief Complaint: Hypoxemia\n HPI:\n Ms. is a 40 year old woman with a history of type 1 diabetes,\n htn, protein C deficiency s/p PE who initially presented with severe\n stabbing RUQ pain, N/V/D x 1 day. Patient had extensive work-up\n including EGD that was thought to be due to diabetic gastroparesis. On\n floor, patient had onset of hypotension and LE edema. Was found to\n have large IVC thrombus by MRV. Patient was taken to IR today for\n localized TPA infusion.\n .\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n # DM, type I\n # CAD s/p NSTEMI per pt report\n # Hypertension\n # Protein C deficiency - tested while on coumadin so not valid\n diagnosis.\n # h/o PE \n - self d/c'ed coumadin\n - s/p IVC filter as per above.\n # Hyperlipidemia\n # ? h/o CHF, ECHO w/o LVH or sys dysfunction (EF>55%)\n # s/p cholecystectomy\n # anemia\n - reportedly normal EGD and colonscopy in at an outside\n hospital per patient report\n Mother with CAD, died MI at 55. Father first MI at 50, DM prostate CA\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Denies TObacco or ETOH Lives at home with husband. children.\n Review of systems:\n Cardiovascular: Chest pain, Palpitations, Edema, No(t) Tachycardia,\n No(t) Orthopnea\n Flowsheet Data as of 07:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Hct 23 this AM, INR 1.2 PTT 53\n pre-procedure, glucose 240\n Imaging: CXR: pending\n Microbiology: No recent data\n ECG: ECG: sinus rhythm with tachycardia, LBBB , nml axis, no ST/T\n changes c/w ischemia No change from prior. No S1,Q3,T3\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis and Post-procedure mgmt: s/p TPA by IR with question\n of anaphylaxis. Procedure complicated by tachycardia, hypoxemia.\n Transferred to ICU for monitoring. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure. No\n evidence for aspiration at this time. Low suspicion for MI by history\n but would rule out with serial enzymes. Lastly might represent CHF\n given e/o volume overload on exam and h/o diastolic dysfunction.\n - 0.5mg/hr TPA on each side for total of 1.0mg/hr\n - 250 units heparin gtt per hour for each sheeth (total 500)\n - no other heparin products to be given\n - Avoid blood draws, arterial sticks or arterial lines\n - frequent neuro checks q2 hours for stroke\n - Coags and fibrinogen q3 hours, h/h q6 hours\n - If fibrinogen < 150, decrease by and recheck in 1 hour.\n - If firbinogen < 100, stop TPA and call IR, can draw from sheaths as\n long as it is flushed with saline.\n - Call IR with any questions.\n - 40mg Prednisone 16, 8 and 2 hour pre-procedure - plan for 10am\n tomorrow.\n - 150mg zantac 1 hour pre-procedure\n - 15mg PO benadryl 1 hour pre-procedure\n .\n #Hypoxemia: PE vs. aspiration vs. CHF vs obsesity hypoventilation and\n derecruitment in setting of procedure and sedation. Question of volume\n overload given h/o diastolic CHF and lying supine for procedure.\n - NRB and wean as tolerated.\n - CXR, ECG, Enzymes, BNP\n - Continue IVF's for now, but consider holding if CXR demonstrates\n volume overload.\n - autoset CPAP overnight\n .\n #Renal Failure: baseline Cr 1.1, now 1.3. Team thought pre-renal\n complicated by slight ATN. Renal ultrasound without obstruction.\n - IVF's, mucomyst, bicarbonate pre-procedure\n - Continue hydration\n - renal ultrasound without obstruction.\n .\n #Hypertension: Has h/o HTN. Will use hydralazine overnight as low\n suspicion for MI, and beta-blockade in setting of PE may precipitate\n hypotension.\n .\n #Tachycardia: Appears to be sinus tach by ECG. PE vs. pain vs.\n agitation.\n - Continue to follow\n - Management as above\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs for promotility. Will d/w GI re why\n not reglan or erythromycin.\n - continue promethazine and dilaudid prn\n - Gastritis - H. Pylori neg, treating with PPI daily\n .\n # UTI: Treated and resolved, follow Cr.\n .\n # Anemia: Continues to trend down and started on Fe replacement.\n Negative EGD. Will need to trend hematocrit on Tpa and heparin.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - Pt unable to tolerate bowel prep now (nausea, renal failure), but if\n diarrhea or worsening anemia persists, will need colonoscopy\n .\n # CAD: Known nonobstructive CAD on recent cath. Normal recent ECHO and\n stress test. given chest pain on presentation will cycle enzmes.\n - no aspirin given allergy\n - continue statin\n - continue holding BP meds\n .\n # Diabetes: Poorly controlled even while NPO. Takes 100 units glargine\n qhs\n - HbA1C 10.8 , 7.9 \n - Continue lantus 100 and HISS\n - Eating today so will restart standing humalog\n - Diabetic diet\n .\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n .\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet, no IVF, lytes prn\n # Access: PICC, 2 femoral sheaths\n # PPx: heparin IV infusion, TPA, no other heparin products at this\n time.\n # Code: presumed FULL\n # Dispo: pending above\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2105-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660317, "text": "40yo female PMH: of PE x2 in and 6/. s/pIVC filter maintained\non coumadin, though noncompliant; DM, type I; CAD s/p NSTEMI per pt report; HTN;\n Protein C deficiency; ? h/o CHF, ECHO w/o LVH or sys dysfunction (EF>5\n5%); Hyperlipidemia admitted to the floor on for RUQ pain EGD on \nrevealed gastroparesis and erosive gastritis. Throughout her hospital course, sh\ne has been noted to have significant progressive lower extremity edema.\n pt sent to IR for thrombolysis/ectomy of IVC fliter. While in IR, after rec\niving angiojet pt, c/o sob, feeling like her\nthroat was closing\n. And desatted\nto the higjh 80%\ns. pt was given benadryl 50mg, placed on 100% non rebreather an\nd her 02 sat quickly improved into the mid 90%\ns. pt non compliant w/ 02 mask sw\nitched to 6L n/c and transferrd to the MICU for further management.\nPt arrived in the MICU w/ TPA at 0.5mg/hr and Heparin 250 units/hr running \n each sheath w/ plan to return to IR in the am to complete procedure. 02 sat 8\n7-88% on 6L upon arrival to MICU, placed on 100% NRB with sats immediately impro\nving to 95-99% b/p 170-192/100\ns, 10mg IV hydralazine given a/o. pt c/o pain and\n nausea, medicated w/ IV dilaudid and phenergan w/ some eff.\nPlan is to cont TPA and heparin overnight and return to IR for completion of pro\ncedure in the am.\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660510, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites and\n right upper quadrant.\n Action:\n PO dilaudid 4mg as well dilaudid 0.25 mg given with some effect. While\n IR tried to change her reg PIVCC line to Power PICC lineshe c/o chest\n pain radiating to her back,done EKG( T inversion ? ),given\n Nitorglycerin .3 mg Sl x2 with some effect.Sent cardiac\n markers,consulting Cardiology\n Response:\n Plan:\n Cont dilaudid 4mg PO q3hrs PRN\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n No change in gtt rate. Cont follow Pt/PTT. Planning to do CTA as soon\n as possible\n Response:\n PTT at 1600 33.4And Hct at 1600 23.5\n Plan:\n Cont heparin/tpa gtts for now.? CTA to tule out PE? . Next set due at\n 1900 .\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660347, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites.\n Action:\n PO dilaudid 4mg\n Response:\n Pain tolerable per pt\n :\n Cont dilaudid 4mg PO q3hrs PRN\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n No change in gtt rate. Following coags/hct q3hrs.\n Response:\n PTT\n Plan:\n Cont heparin/tpa gtts. Pt to IR to complete prodedure.\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Nursing", "chartdate": "2105-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660355, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o generalized body pain but more intense around insertion sites.\n Action:\n PO dilaudid 4mg\n Response:\n Pain tolerable per pt\n :\n Cont dilaudid 4mg PO q3hrs PRN\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters w/ [1]tpa @ 0.5mg/hr and heparin @ 250u/hr.\n +pedal pulses, dressings C/D/I.\n Action:\n No change in gtt rate. Following coags/hct q3hrs.\n Response:\n @3am PTT 41.1/fib 218\n Plan:\n Cont heparin/tpa gtts. Pt to IR to complete prodedure. Draw coags/hct\n @6am.\nReferences\n 1. mailto:[email protected]/hr\n" }, { "category": "Nursing", "chartdate": "2105-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660532, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters in place with NS at 50cc/hr running through\n each sheath. +pedal pulses, bilat lower extremities warm. Dressings\n C/D/I. Pt. also received on heparin gtt at 1000u/hr. Midnight PTT 32.\n Pt.remains a+o. No s/s of bleeding.\n Action:\n Pt. bolused with 2000u of heparin and gtt increased to 1300u/hr per\n sliding scale.\n Response:\n Next PTT to be drawn at 0700. Pt. hemodynamically stable.\n Plan:\n CTA to rule out PE? . Draw next PTT at 0700. ? if pt. will be going\n back to IR today.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. Started on insulin gtt yesterday\n as she was hypoglycemic with poor glucose control. Received on gtt at\n 14u/hr. Throughout shift, blood sugars trending down. Gtt titrated per\n insulin protocol.\n Action:\n Insulin gtt titrated to maintain fasting sugars between 100 to 150.\n Finger sticks checked Q1h\n Response:\n Blood sugars between 100 and 150 throughout shift with insulin titrated\n down to 1u/hr.\n Plan:\n Continue to check sugars Q1h. Titrate insulin gtt according to\n protocol.\n" }, { "category": "Nursing", "chartdate": "2105-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660547, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Of note: Hct this am 20 (down from 23 last evening) Pt. ordered for 1U\n PRBCs to be given over 2 hours. Type and Cross sent to blood bank.\n Waiting for blood to be ready at this time.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters in place with NS at 50cc/hr running through\n each sheath. +pedal pulses, bilat lower extremities warm. Dressings\n C/D/I. Pt. also received on heparin gtt at 1000u/hr. Midnight PTT 32.\n Pt.remains a+o. No s/s of bleeding. Pt. remains on 50% FIO2 via high\n flow neb with sats >97%, C/O pain with breathing.\n Action:\n Pt. bolused with 2000u of heparin and gtt increased to 1300u/hr per\n sliding scale. Medicated with dilaudid 0.25mg prn pleuritic pain.\n Cardiac enzymes cycled.\n Response:\n Next PTT to be drawn at 0700. Pt. hemodynamically stable. Pain relieved\n with dilaudid prn.\n Plan:\n CTA to rule out PE? . Draw next PTT at 0700. ? if pt. will be going\n back to IR today. Medicate with pain meds as needed.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt. with history of diabetes type 1. Started on insulin gtt yesterday\n as she was hypoglycemic with poor glucose control. Received on gtt at\n 14u/hr. Throughout shift, blood sugars trending down. Gtt titrated per\n insulin protocol.\n Action:\n Insulin gtt titrated to maintain fasting sugars between 100 to 150.\n Finger sticks checked Q1h\n Response:\n Blood sugars between 100 and 150 throughout shift with insulin titrated\n down to 1u/hr.\n Plan:\n Continue to check sugars Q1h. Titrate insulin gtt according to\n protocol.\n" }, { "category": "Nursing", "chartdate": "2105-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660530, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow today. Also, needs\n abdominal/pulm CT to r/o PE.\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n R and L femoral catheters in place with NS at 50cc/hr running through\n each sheath. +pedal pulses, bilat lower extremities warm. Dressings\n C/D/I. Pt. also received on heparin gtt at 1000u/hr. Midnight PTT 32.\n Pt.remains a+o. No s/s of bleeding.\n Action:\n Pt. bolused with 2000u of heparin and gtt increased to 1300u/hr per\n sliding scale.\n Response:\n Next PTT to be drawn at 0700. Pt. hemodynamically stable.\n Plan:\n CTA to rule out PE? . Draw next PTT at 0700. ? if pt. will be going\n back to IR today.\n" }, { "category": "Physician ", "chartdate": "2105-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660619, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 03:18 PM\n EKG - At 04:50 PM\n BLOOD CULTURED - At 05:00 PM\n TRANS ESOPHAGEAL ECHO - At 05:00 PM\n Events:\n - renal recommended not to do CTA bc dye load, will get CT n/c chest in\n AM to eval PNA\n - patient around 6pm had chest pain, TWI in V1,2, cardiology notified,\n no MI, started heparin drip with weight based protocol\n - continuing to cycle enzymes\n - IR placed power PICC, now appropriately positioned\n - echo\n no new RV strain or hemorrhagic conversion of stable small\n pericardial effusion, stable from \n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Ciprofloxacin - 10:00 PM\n Aztreonam - 03:18 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Heparin Sodium - 12:53 AM\n Lorazepam (Ativan) - 03:17 AM\n Hydromorphone (Dilaudid) - 05:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.8\n HR: 90 (85 - 119) bpm\n BP: 117/49(64) {108/40(55) - 161/74(91)} mmHg\n RR: 15 (11 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,514 mL\n 1,705 mL\n PO:\n TF:\n IVF:\n 8,514 mL\n 1,529 mL\n Blood products:\n 175 mL\n Total out:\n 1,910 mL\n 280 mL\n Urine:\n 1,760 mL\n 280 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 6,604 mL\n 1,425 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding, no grey- or cullen\ns signs\n Extremities: Right: 2+, Left: 2+, no evidence of fem hematoma\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli,\n Labs / Radiology\n 300 K/uL\n 7.0 g/dL\n 114 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 20.2 %\n 10.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n WBC\n 11.7\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n Plt\n 384\n 371\n 375\n \n Cr\n 1.5\n 1.4\n 1.5\n TropT\n 0.02\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 73\n 114\n Other labs: PT / PTT / INR:16.2/35.0/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis: Patient is s/p TPA by IR with question of anaphylaxis\n manifested tachycardia and hypoxemia. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure vs possible\n aspiration PNA on CXR . Low suspicion for MI by history ruled out\n with serial enzymes. Stopped heparin ggt through fem catheters once\n power PICC placed.\n .\n #Hypoxemia: PE vs. pulmonary infarct vs. aspiration vs obsesity\n hypoventilation and derecruitment in setting of procedure and\n sedation. PE high-risk given clot burden and peri-procedure;\n aspiration/HAP given body habitus, leukocytosis and low grade fever;\n CHF less likely given unilateral findings on CXR, BNP.\n - currently on face mask, wean O2 as tolerated\n - will obtain induced sputum cx\n - vanc/ Aztreonam /cipro for HAP/aspiration\n - will perform non-contrast CT (investigate pulmonary infiltrate) and\n venogram (holding for now given ARF.\n .\n #Renal Failure: Baseline Cr 1.1. Likely pre-renal complicated by ATN\n from contrast nephropathy. Renal ultrasound without obstruction.\n - Renal following, recs no dye load at this time, holding off on\n venogram for now\n - when okay with renal, will give prehydration protocol - IVF's,\n mucomyst, bicarbonate pre-procedure\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis , H. Pylori neg.\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs and reglan for promotility.\n - continue dilaudid prn pain and ativan for nausea given allergy\n profile\n - Gastritis - treating with PPI daily\n .\n # Anemia: Concerning in the setting of heparin ggt and TPA\n administration and s/p multiple procedures.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - pan-scan CT , eval for femoral bleed and RP bleed\n .\n # CAD: Known non-obstructive CAD on recent cath. Normal recent ECHO and\n stress test. Given chest pain on presentation will cycle enzmes -> CEs\n negative. EKG with TWI in V1 and V2. Cardiology shown EKG, no ACS.\n On heparin ggt for thrombosis.\n - no aspirin given allergy\n - continue statin\n - will add BP meds as tolerated\n - obtained rpt EKG , resolving TWI\n .\n # DM1:, needs basal insulin. Poorly controlled even while NPO. Takes\n 100 units glargine qhs, HbA1C 10.8 , 7.9 \n - continue insulin gtt until tolerating PO, FS 100-150, checking FS Q1H\n - Diabetic diet\n .\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n #Hypertension: Has h/o HTN. Received one dose of hydralazine PM\n as low suspicion for MI, and beta-blockade in setting of PE may\n precipitate hypotension.\n - will add home regimen as BP tolerates\n .\n # treated UTI: Treated and resolved.\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet, lytes prn\n # Access: power PICC, 2 femoral sheaths pulled \n # PPx: heparin ggt for thrombosis, PPI, bowel regimen\n # Code: FULL\n # Dispo: pending above , currently on insulin ggt\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660575, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 03:18 PM\n EKG - At 04:50 PM\n BLOOD CULTURED - At 05:00 PM\n TRANS ESOPHAGEAL ECHO - At 05:00 PM\n Events:\n - renal recommended not to do CTA bc dye load, will get CT n/c chest in\n AM to eval PNA\n - patient around 6pm had chest pain, TWI in V1,2, cardiology notified,\n no MI, started heparin drip with weight based protocol\n - continuing to cycle enzymes\n - IR placed power PICC, now appropriately positioned\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Ciprofloxacin - 10:00 PM\n Aztreonam - 03:18 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Heparin Sodium - 12:53 AM\n Lorazepam (Ativan) - 03:17 AM\n Hydromorphone (Dilaudid) - 05:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.8\n HR: 90 (85 - 119) bpm\n BP: 117/49(64) {108/40(55) - 161/74(91)} mmHg\n RR: 15 (11 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,514 mL\n 1,705 mL\n PO:\n TF:\n IVF:\n 8,514 mL\n 1,529 mL\n Blood products:\n 175 mL\n Total out:\n 1,910 mL\n 280 mL\n Urine:\n 1,760 mL\n 280 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 6,604 mL\n 1,425 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 300 K/uL\n 7.0 g/dL\n 114 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 20.2 %\n 10.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n WBC\n 11.7\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n Plt\n 384\n 371\n 375\n \n Cr\n 1.5\n 1.4\n 1.5\n TropT\n 0.02\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 73\n 114\n Other labs: PT / PTT / INR:16.2/35.0/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660576, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 03:18 PM\n EKG - At 04:50 PM\n BLOOD CULTURED - At 05:00 PM\n TRANS ESOPHAGEAL ECHO - At 05:00 PM\n Events:\n - renal recommended not to do CTA bc dye load, will get CT n/c chest in\n AM to eval PNA\n - patient around 6pm had chest pain, TWI in V1,2, cardiology notified,\n no MI, started heparin drip with weight based protocol\n - continuing to cycle enzymes\n - IR placed power PICC, now appropriately positioned\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:10 PM\n Ciprofloxacin - 10:00 PM\n Aztreonam - 03:18 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Heparin Sodium - 12:53 AM\n Lorazepam (Ativan) - 03:17 AM\n Hydromorphone (Dilaudid) - 05:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.8\n HR: 90 (85 - 119) bpm\n BP: 117/49(64) {108/40(55) - 161/74(91)} mmHg\n RR: 15 (11 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,514 mL\n 1,705 mL\n PO:\n TF:\n IVF:\n 8,514 mL\n 1,529 mL\n Blood products:\n 175 mL\n Total out:\n 1,910 mL\n 280 mL\n Urine:\n 1,760 mL\n 280 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 6,604 mL\n 1,425 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 300 K/uL\n 7.0 g/dL\n 114 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 20.2 %\n 10.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n WBC\n 11.7\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n Plt\n 384\n 371\n 375\n \n Cr\n 1.5\n 1.4\n 1.5\n TropT\n 0.02\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 73\n 114\n Other labs: PT / PTT / INR:16.2/35.0/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-03-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 660601, "text": "Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Continued hypoxemia\n VBG pCO2 was reassuring\n Chest pain; EKG reviewed with cardiology\n Echo showed no RV dilation, no increase in pericardial effusion, and no\n LV regional wall motion abnormalities.\n PowerPICC placed\n TPA infusion catheters removed\n Therapeutically heparinized\n Hct fell\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Aztreonam - 03:18 AM\n Vancomycin - 08:40 AM\n Infusions:\n Insulin - Regular - 1 units/hour\n Heparin Sodium - 1,450 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 05:32 AM\n Pantoprazole (Protonix) - 08:40 AM\n Heparin Sodium - 08:45 AM\n Lorazepam (Ativan) - 08:47 AM\n Other medications:\n reglan, iron, statin, cipro, aztreonam, vanco, insulin gtt, klonopin,\n ativan, PPI, heparin gtt\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.8\nC (98.3\n HR: 92 (83 - 119) bpm\n BP: 118/45(62) {107/39(55) - 157/74(91)} mmHg\n RR: 15 (11 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,514 mL\n 2,319 mL\n PO:\n TF:\n IVF:\n 8,514 mL\n 2,035 mL\n Blood products:\n 284 mL\n Total out:\n 1,910 mL\n 380 mL\n Urine:\n 1,760 mL\n 380 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 6,604 mL\n 1,939 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anterior exam)\n Abdominal: Soft, continued abdominal discomfort with palpation\n Extremities: Right: edema present, Left: edema present\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Groin sites intact, but difficult to evaluate given habitus\n Labs / Radiology\n 7.0 g/dL\n 300 K/uL\n 114 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 20.2 %\n 10.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n 09:34 AM\n 09:38 AM\n 04:44 PM\n 09:19 PM\n 02:16 AM\n WBC\n 11.7\n 15.4\n 16.0\n 13.6\n 12.3\n 10.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n 24.0\n 23.5\n 20.2\n Plt\n 384\n 371\n 375\n \n Cr\n 1.5\n 1.4\n 1.5\n TropT\n 0.02\n 0.04\n 0.02\n 0.03\n 0.03\n 0.02\n Glucose\n 73\n 114\n Other labs: PT / PTT / INR:15.7/48.2/1.4, CK / CKMB /\n Troponin-T:185/2/0.02, ALT / AST:13/13, Alk Phos / T Bili:59/0.3,\n Amylase / Lipase:31/12, Differential-Neuts:79.2 %, Band:0.0 %,\n Lymph:12.9 %, Mono:7.0 %, Eos:0.5 %, Fibrinogen:220 mg/dL, Lactic\n Acid:1.3 mmol/L, Albumin:2.7 g/dL, LDH:566 IU/L, Ca++:8.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 40-year-old woman with\n Marked deep venous thrombosis, including IVC filter clot\n Hypoxemia\n improving somewhat\n Probable aspiration pneumonia (vs. pulmonary edema, though\n dought)\n Acute renal failure\n improving\n Obesity and probable OSA\n Contrast allergy\n Etiology of hypoxemia remains uncertain. CXR suggests pneumonia; PE\n is in DDx. We will complete a course of therapy for HAP x 8 days if\n unable to get cultures, and try to get sputum (none so far). Since she\n has known DVT (and therefore will be anticoagulated), and RV is not\n dilated, we have held off on CTA, since she is at higher-than-average\n risk for contrast-induced ARF.\n Tachycardia appears to have been mostly hypovolemic based on response\n to fluids\n [image004.gif]\n Diabetes\n continue insulin gtt today\n Nausea/Vomiting\n as per ICU team note\n DVT\n now off of TPA, on therapeutic heparin\n Anemia\n fall is meaningful, and she is without obvious clinical\n bleeding. Guaiac stools. Given groin access, will CT abd and thighs.\n Other issues as per ICU team note today.\n ICU Care\n Nutrition: cautiously advance diet after CTs today\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2105-03-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 660404, "text": "TITLE:\n Chief Complaint: respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Continued hypoxemia, essentially stable.\n Hypertension better controlled\n Says her dyspnea is improved\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 250 units/hour\n Other ICU medications:\n Hydralazine - 06:30 PM\n Other medications:\n heparin, TPA, NAC, prednisone @ 40, Reglan, iron, PPI, SQI, statin,\n Klonopin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 102 (96 - 118) bpm\n BP: 138/59(79) {125/59(77) - 185/92(112)} mmHg\n RR: 24 (20 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,924 mL\n 2,626 mL\n PO:\n TF:\n IVF:\n 1,924 mL\n 2,626 mL\n Blood products:\n Total out:\n 340 mL\n 790 mL\n Urine:\n 340 mL\n 690 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,584 mL\n 1,836 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), anterior exam; unable\n to examine posterior due to groin catheters\n Abdominal: Soft, Tender: continued discomfort with palpation\n Extremities: Right: 2+ edema, Left: 2+ edema\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 371 K/uL\n 217 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 106 mEq/L\n 138 mEq/L\n 26.3 %\n 15.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n WBC\n 11.7\n 15.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n Plt\n 384\n 371\n Cr\n 1.5\n 1.4\n TropT\n 0.02\n 0.04\n Glucose\n 215\n 217\n Other labs: PT / PTT / INR:15.3/34.8/1.4, CK / CKMB /\n Troponin-T:175/3/0.04, Differential-Neuts:89.3 %, Lymph:4.6 %, Mono:5.3\n %, Eos:0.6 %, Fibrinogen:249 mg/dL, Ca++:8.1 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.8 mg/dL\n CXR today shows increased right base opacity and left base\n consolidation\n Assessment and Plan\n 40-year-old woman with\n Marked deep venous thrombosis, including IVC filter clot\n Hypoxemia\n Acute renal failure\n improving\n Obesity and probable OSA\n Contrast allergy\n We have discussed with the IR team. They favor CT imaging to assess\n clot burden, as well as\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT: Boots(on local heparin and TPA)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2105-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 660414, "text": "Chief Complaint:\n 24 Hour Events:\n -no acute events overnight\n -pt still with high O2 requirements\n Allergies:\n Penicillins\n Hives;\n Aspirin\n Hives;\n Motrin (Oral) (Ibuprofen)\n Hives;\n Tylenol (Oral) (Dm Hb/Pseudoephed/Acetamin/Cp)\n Hives;\n Codeine\n Hives;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Hives;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Shortness of br\n Zofran (Oral) (Ondansetron Hcl)\n Hives;\n Morphine\n Shortness of br\n Optiray 320 (Intraven) (Ioversol)\n Hives;\n Visipaque (Injection) (Iodixanol)\n Hives;\n Tramadol\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Alteplase (TPA) - 0.5 mg/hour\n Heparin Sodium - 250 units/hour\n Other ICU medications:\n Hydralazine - 06:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 104 (96 - 118) bpm\n BP: 166/75(96) {125/60(77) - 185/92(112)} mmHg\n RR: 28 (20 - 28) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,924 mL\n 2,226 mL\n PO:\n TF:\n IVF:\n 1,924 mL\n 2,226 mL\n Blood products:\n Total out:\n 340 mL\n 610 mL\n Urine:\n 340 mL\n 510 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,584 mL\n 1,616 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases)\n Abdominal: Soft, Bowel sounds present, Distended, Tender: RUQ w/o\n rebound, mild guarding\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 371 K/uL\n 8.7 g/dL\n 217 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 106 mEq/L\n 138 mEq/L\n 26.3 %\n 15.4 K/uL\n [image002.jpg]\n 06:20 PM\n 08:54 PM\n 11:51 PM\n 03:02 AM\n 05:37 AM\n WBC\n 11.7\n 15.4\n Hct\n 26.5\n 25.7\n 26.3\n 25.1\n 26.3\n Plt\n 384\n 371\n Cr\n 1.5\n 1.4\n TropT\n 0.02\n 0.04\n Glucose\n 215\n 217\n Other labs: PT / PTT / INR:15.3/34.8/1.4, CK / CKMB /\n Troponin-T:175/3/0.04, Fibrinogen:249 mg/dL, Ca++:8.1 mg/dL, Mg++:1.6\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 40 year old woman with a history of type 1 diabetes, CAD, htn, s/p PE\n with IVC filter in place now found to have large IVC thrombosis\n transferred to MICU for observation s/p TPA by IR.\n .\n # IVC Thrombosis and Post-procedure mgmt: s/p TPA by IR with question\n of anaphylaxis. Procedure complicated by tachycardia, hypoxemia.\n Transferred to ICU for monitoring. Hypoxemia and tachycardia likely\n to multiple small PE as a consequence of the procedure. Possible\n aspiration PNA on CXR . Low suspicion for MI by history and will\n continue to rule out with serial enzymes. Lastly might represent CHF\n given e/o volume overload on exam and h/o diastolic dysfunction,\n however abnormalities on CXR appear unilateral.\n - 0.5mg/hr TPA on each side for total of 1.0mg/hr\n - 250 units heparin gtt per hour for each sheeth (total 500)\n - no other heparin products to be given\n - Avoid blood draws, arterial sticks or arterial lines\n - frequent neuro checks q2 hours for stroke\n - Coags and fibrinogen q3 hours, h/h q6 hours\n - If fibrinogen < 150, decrease by and recheck in 1 hour.\n - If firbinogen < 100, stop TPA and call IR, can draw from sheaths as\n long as it is flushed with saline.\n - 40mg Prednisone 16, 8 and 2 hour pre-procedure - plan for 10am today\n - 150mg zantac 1 hour pre-procedure\n - 15mg PO benadryl 1 hour pre-procedure\n .\n #Hypoxemia: PE vs. aspiration vs. CHF vs obsesity hypoventilation and\n derecruitment in setting of procedure and sedation. PE high-risk given\n clot burden and peri-procedure; aspiration/HAP given body habitus,\n leukocytosis and low grade fever; CHF less likely given unilateral\n findings on CXR, BNP.\n - check ABG today\n - trial on venti-mask to assess O2 requirements\n - send sputum cxs\n - vanc//cipro for HAP/aspiration\n - if can obtain PIV access will perform CTA to investigate PE (would\n require more aggressive anticoagulation) and venogram to investigate\n status of IVC. If only have PICC access will perform non-contrast CT\n (investigate pulmonary infiltrate) and venogram.\n .\n #Renal Failure: Baseline Cr 1.1. Likely pre-renal complicated by ATN\n from contrast nephropathy. Renal ultrasound without obstruction.\n - IVF's, mucomyst, bicarbonate pre-procedure\n - renal ultrasound without obstruction\n .\n #Hypertension: Has h/o HTN. Received one dose of hydralazine PM\n as low suspicion for MI, and beta-blockade in setting of PE may\n precipitate hypotension.\n - will add home regimen as BP tolerates\n .\n # RUQ abdominal pain: Likey due to diabetic gastroparesis and erosive\n gastritis\n - N/V/D fluctuating, pain slightly improved.\n - gastroparesis explains most symptoms, except diarrhea/fevers (has\n been afebrile)\n - will need gastric emptying study as outpt\n - treating with amitriptyline qhs for promotility. Will d/w GI re why\n not reglan or erythromycin.\n - continue promethazine and dilaudid prn\n - Gastritis - H. Pylori neg, treating with PPI daily\n .\n # UTI: Treated and resolved, follow Cr.\n .\n # Anemia: Continues to trend down and started on Fe replacement.\n Negative EGD. Will need to trend hematocrit on TPA and heparin.\n - anemia panel c/w AOCD and -> will start PO iron repletion.\n - RDW elevated - macrocytosis likely due to low retic count (? due to\n low iron vs poor BM function)\n - Pt unable to tolerate bowel prep now (nausea, renal failure), but if\n diarrhea or worsening anemia persists, will need colonoscopy\n .\n # CAD: Known non-obstructive CAD on recent cath. Normal recent ECHO and\n stress test. Given chest pain on presentation will cycle enzmes -> CEs\n negative.\n - no aspirin given allergy\n - continue statin\n - will add BP meds as tolerated\n .\n # Diabetes: Poorly controlled even while NPO. Takes 100 units glargine\n qhs\n - HbA1C 10.8 , 7.9 \n - start insulin gtt given poor control of BS\n - Diabetic diet\n .\n # Hypercoagulability: Appreciate heme-onc rec's, will check factor V\n leiden as per heme-onc. Do not believe diagnosis of protein C\n deficiency is valid at this time.\n .\n # Hyperlipidemia: Tg 280, LDL 225, CHol 303\n - continue statin\n .\n # FEN: Diabetic diet,IVF, lytes prn\n # Access: PICC, 2 femoral sheaths, will attempt to get PIV access for\n CTA\n # PPx: heparin IV infusion, TPA, no other heparin products at this time\n -> will need to transition to long-term anticoagulation based on CTA\n results\n # Code: presumed FULL\n # Dispo: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 09:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2105-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 660526, "text": "40 year old woman with a history of DM1, HTN, protein C deficiency s/p\n PE who initially presented with severe stabbing RUQ pain, N/V/D x 1\n day. Patient had extensive work-up including EGD that was thought to be\n due to diabetic gastroparesis. On floor, patient had onset of\n hypotension and LE edema. Was found to have large IVC thrombus by\n MRV. Patient was taken to IR for localized TPA infusion.\n IR obtained access into both femoral veins. Venogram demonstrated near\n complete occlusion of L-external and left common iliac. Partial\n occlusion of R-external, common and IVC. Patient has h/o contrast\n allergy. Was pre-medicated with benadryl/steroids/zantac. Was\n hypoxemic during procedure as low as 80% on NRB. Is now 95% on NRB.\n HR to 150's peri-procedure, and c/o throat tightness. Question\n contrast reaction. Epinephrine deferred and procedure stopped. TPA\n infusion catheters placed into external iliac into IVC. TPA and\n heparin overnight. Plan to reasses in IR tomorrow AM.\n" } ]

[ { "category": "Radiology", "chartdate": "2151-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947121, "text": " 4:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with CAD s/p CABG, now with runs of SVT and SOB, desatting\n to 80's.\n REASON FOR THIS EXAMINATION:\n eval for failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman with CAD status post CABG, now with SVT and\n shortness of breath as well as hypoxia.\n\n COMPARISON: Chest x-ray from .\n\n AP UPRIGHT CHEST: The patient is status post median sternotomy and CABG.\n There is diffuse interstitial abnormality, with small nodular regions, more\n evident than on the prior studies. In addition, there are new small bilateral\n pleural effusions. There is likely bilateral lower lobe atelectasis.\n\n IMPRESSION:\n 1. Diffuse interstitial abnormality, which raises the possibility of a more\n chronic process such as hemosiderosis resulting from pulmonary edema. A PA\n and lateral study may be of value.\n 2. New small bilateral pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2151-02-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 947942, "text": " 2:24 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate for pneumothorax and lead placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with new single lead ICD via right axillary vein\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax and lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old female with new single lead ICD via right axillary\n vein.\n\n COMPARISON: AP upright portable chest x-ray .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A right chest wall single lead\n pacemaker/ defibrillator is in appropriate position. The proximal\n electrode is adjacent to the SVC. There is no pneumothorax. The cardiac\n silhouette is upper limits of normal, but stable. The mediastinal and hilar\n contours are within normal limits. The patient is status post sternotomy and\n CABG. A diffuse interstitial abnormality is unchanged since multiple prior\n exams. There are no focal consolidations, and no effusion.\n\n IMPRESSION: Status post right chest wall single lead pacemaker/defibrillator\n without pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2151-02-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 948033, "text": " 10:22 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for lead placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with new single chamber ICD\n REASON FOR THIS EXAMINATION:\n evaluate for lead placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 57-year-old woman with new single-chamber ICD. Evaluate for lead\n placement.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been no interval change in the position of the single-lead AICD.\n Mediastinotomy wires are seen. There is again noted prominence of the\n interstitial markings bilaterally. Underlying pulmonary edema cannot be\n excluded, however, these findings are stable when compared to multiple prior\n radiographs. No pleural effusions are seen.\n\n\n\n\n\n" }, { "category": "Echo", "chartdate": "2151-02-22 00:00:00.000", "description": "Report", "row_id": 64498, "text": "PATIENT/TEST INFORMATION:\nIndication: Dyssynchrony Only.\nHeight: (in) 67\nWeight (lb): 139\nBSA (m2): 1.73 m2\nBP (mm Hg): 92/58\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 10:33\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Depressed LVEF. TSI demonstrates significant LV dyssynchrony\nwith significant lateral wall contraction delay (vs. septum). The aortic\npre-ejection time is normal (<140ms). The delay between LV and RV ejection is\nnormal (<40ms). The left ventricle is dyssnchronous with global asynchrony\n() index >33ms.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\nakinetic;\n\nConclusions:\nLV systolic function appears depressed with apical and lateral hypokinesis\n(regional motion not fully assesed; focused views only). Tissue\nsynchronization imaging demonstrates significant left ventricular dyssynchrony\nwith the lateral wall contracting 105 ms later than the septum. The aortic\npre-ejection time is normal at 42 (nl <140ms). The delay between left\nventricular and right ventricular ejection is 14 (nl <40ms). The left\nventricle is dyssnchronous with global synchrony () index of 52 ms (nl\n<=33ms).\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-02-22 00:00:00.000", "description": "Report", "row_id": 1359198, "text": "SR C PVCS.BP 90S SYSTOLIC.DIURESED ,RECIEVED PO LISINOPRIL BUT METROPROLOL XL HELD .\n\nBS C CRACKLES,SAT 97 ON 2L NP .SOB ESPECIALLY WHEN SPEAKING .\n\nTAKING PO FAIR ,POS BS NO STOOL\n\nAIM NEG 500CC,CYU VIA FOLEY\n\nPT MED FOR PAIN X1 C ULTRAM FOR PAIN CAUSED BY ULCER ,SLEEPING MOST OF DAY .VSITING C HUSBAND .ULCER CLEAN ,DUODERM GEL C DSD HYPERFIX TAPE,AWAITING WOUND NURSE CONSULT .\n\nREPONDING TO AGGRESSIVE DIURESIS\n\nRECHECK LYTES THIS PM\nENCOURAGE PO\nMONITOR FLUID STATUS\nWOUND CARE\n" }, { "category": "Nursing/other", "chartdate": "2151-02-23 00:00:00.000", "description": "Report", "row_id": 1359199, "text": "Nursing Progress Note\n\nS:\"I'm worried about this other test I might have.\"\n\nO: Tele remains in sinus rhythm with frequent PVC's including short nonsustained runs. Metoprolol XL remains on hold. SBP overnight via NI cuff 78-88. House staff aware. Pt is asymptomatic. Dose of zaroxlyn and lasix held in the pm.\n\nResp: Pt c/o feeling short of breath at rest. Pt not appearing to be in distress. Having short periods of apnea. Pt denies chest pain. O2 sats have been >96% on 2l Lungs with rales in the bases.\n\nNeuro: Pt is alert and oriented x's 3. Voice is soft. Conts to have R sided weakness from previous stroke. Feeling anxious about the possible of another intervention. Given Ultram for back/coccyx pain. Slept off and on after receiving Trazadone for sleep.\n\nGI/GU: Abd is soft with bowel sounds present. No BM since admit. Foley draining CYU creat 1.3.\n\nSkin: Dsg over coccyx remains intact.\n\nA&P: SBP decreased with diuresis. ? ablilty to diurese further. Offer emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-23 00:00:00.000", "description": "Report", "row_id": 1359200, "text": "ccu nursing progress note\ns: i just feel a little nauseaous\no: pls see carevue flowsheet for complete vs/data/events\nhad 2 episodes of vomiting today,after drinking liquid. 2nd episode ahortly after taking sev mouthfuls of soup. was not choking, min gagging. c/o mod nausea post. denied cp, abd discomfort. rec'd anzamet this am w some effect. team aware and have examined pt.\ncv: hr 80s sr w apcs, occ pvcs. bp 74-90/40-50. pt denys lightheadedness, dizzyness. appears pale, skin cool but dry. holding lopressor and lisinopril per bp parameter.has not yet rec'd diuretic d/t hypotension. team informed of this.\ninr 2.4.\ndr spoke w pt and husband today re placing icd. after discussing w husband pt has agreed to proceed w procedure.\nresp: crackles at bases. sob w effort. rr 12-24 at rest. on 2l nc w sats 95-100%.\ngi: vomiting today. abd soft, nontender. no stool. declined colace.\ngu: foley to . conc urine. cr stable. diuretic held d/t bp.\nskin: coccyx w stage 1 decub. assessed by skin care rn. plan to cont daily washing w wound spray, duoderm gel on gauze. pt remains off when in bed, primarily on r hip.\nsocial: husband visiting today. voicing concerns and frustration about lack of comunication on team and with him regarding plans for (part upset over discussion of transplant evaluation....\"nothing is to be done without the big bald ok!\"). adamant that she have a designated primary cardiologist who will follow her care during hospital stay and after. , who has been following her as the CHF service, has met w pt and husband and when pt transfers out of the icu he will be her attending then and going forward.\na: hypotensive, nv\np: follow hemodynamics, monitor volume status. follow resp exam, sats. monitor gi system, med for n/v as indicated. assess cause n/v. skin care. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-23 00:00:00.000", "description": "Report", "row_id": 1359201, "text": "CCU NSG NOTE: ALT IN CV/FAILURE\nS: \"I just feel lousy\"\nO: For complete VS see CCU flow sheet.\nID: Pt t max 99.1 orally.\nCV: BP remains low, ranging 75-94/40-50s. She is lethargic and intermittently nauseated. She has agreed to pacemaker placement on . She received no cardiac meds today.\nRESP: She has some fine crackles at bases, and breath sounds very decreased on dependent side. She is sating 98-100% on 2L NP. She has no c/o of SOB.\nRENAL: Urine output poor-9-30cc/hr, but she has had almost nothing in. She is ~150cc neg for the day.\nGI: SHe did not eat anything today. No vomiting this evening. She received 25mg IV anzemet at .\nCOMFORT: She c/o of pain of healing coccyx decub. She received ult5ram 50mg po at 1600 and . She is sleeping now.\nA: Continued hypotension/nausea, unable to eat/u/o decreasing\nP: ? start IVF if pt remains unable to drink. Monitor for significant change. Cont to maintain comfort. NPO after midnight tomorrow night for pacemaker .\n" }, { "category": "Nursing/other", "chartdate": "2151-02-24 00:00:00.000", "description": "Report", "row_id": 1359202, "text": "ccu nsg progress note.\no:neuro=responsive. appropriate.\n pulm=breath sounds w crackles @ bases. sats upper 90's on 2l nc.\n cv=low bp-sbp ranging 70-80's.\n gi=sl improved po intake.\n renal=poor uo.\n id=afebrile.\n labs=am sent.\n\na:awaiting perm pacemake placement-?.\n\np:contin present management. support pt/family as indicated. ?call-out.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-22 00:00:00.000", "description": "Report", "row_id": 1359197, "text": "CCU\nNursing Admit Note\nThis is a 57 year old female admitted from rehab via the EW with worsening shortness of breath.\nSignificant Past Medical History\nMoyamoya Syndrome\nCVA in and with resultant mild dysphagia\nSeizure Disorder\nCABG in with stent to SVG-LAD in \nAortobifem BPG\nRecent Admission from with STEMI with thrombus to SVG-LAD ..Cath complicated by VF arrest times 2 during procedure..with prolonged intubation and IAB support.\nAggressive treatment for severe MR .. To on .\n\nNKDA\n\nCV\nHeart rate 80-90's..with multi focal pvcs ..lytes normal..First cpk flat. SBP 80-90's/40's at baseline. Denies chest pain. Bedside echo in EW with EF of 10%. 4+MR .. 3+TR. INR 5.\n\nResp Baseline RR 28-32..Tachypneic. Speaking in short sentences. 02 sat 96%. Bibas cxs. CXR with mild pulm edema. Lasix increased ti 100 mg . Patient refusing CPAP.\n\nGi/GU Urine output per flowsheet.\n\nID Afebrile. WBC's NL\n\nNeuro Alert and Oriented\n\nFull Code\n\nTo the CCU .. Hemodynamically stable. Diuretics given upon arrival. require swan insertion to maximize afterload IV therapy.\n\n\n" }, { "category": "ECG", "chartdate": "2151-02-27 00:00:00.000", "description": "Report", "row_id": 133362, "text": "Sinus rhythm and frequent ventricular ectopy. Low limb lead voltage. Left\natrial abnormality. Probable anterior myocardial infarction. Compared to the\nprevious tracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2151-02-23 00:00:00.000", "description": "Report", "row_id": 133363, "text": "Sinus rhythm\nMultiform PVCs\nLeft atrial abnormality\nPossible anterior infarct - age undetermined\nST-T changes are nonspecific\nGeneralized low QRS voltages\nSince previous tracing, ventricular premature complex new\n\n" }, { "category": "ECG", "chartdate": "2151-02-21 00:00:00.000", "description": "Report", "row_id": 133365, "text": "Sinus rhythm. Left atrial abnormality. Low limb lead voltage. Prior anterior\nmyocardial infarction. Compared to the previous tracing of the T waves\nare less inverted in the anterolateral leads and ventricular ectopy is abasent.\nOtherwise, no diagnostic interval change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2196-07-02 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 965571, "text": " 10:47 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: r/o DVT, abscess\n Admitting Diagnosis: NAUSEA,UNABLE TO TAKE PO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with erythema/warmth/tenderness in LUE after IV infiltration\n in the L antecubital fossa during a dextrose infusion\n REASON FOR THIS EXAMINATION:\n r/o DVT, abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Erythema, warmth, and tenderness in the left upper extremity\n after IV infiltration. Please evaluate for DVT or abscess.\n\n FINDINGS: -scale, color, and pulse wave Doppler son were performed\n of the left internal jugular, subclavian, axillary, brachial, basilic, and\n cephalic veins. Normal flow, compressibility, waveforms, and augmentation is\n demonstrated, although there is slightly decreased respiratory variability\n seen only in the left subclavian vein. No intraluminal thrombus is\n identified. No discrete fluid collection is identified to suggest abscess.\n\n IMPRESSION: No evidence of DVT or abscess in the left upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2196-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 965272, "text": " 11:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n Admitting Diagnosis: NAUSEA,UNABLE TO TAKE PO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman h/o iddm with hypoglycemia\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoglycemia in a patient with known diabetes\n mellitus.\n\n Portable AP chest radiograph compared to .\n\n The heart size is normal. Mediastinal contours, position, and width are\n unremarkable. The lung volumes are generally low. Crowdedness of the lung\n vessels in both bases is demonstrated accompanied by small patchy areas of\n consolidation, especially in the left retrocardiac space which may represent\n atypical bacterial or viral infection. The possibility of the upper lung\n redisrtribution of the blood flow cannot be excluded, and might reflect\n minimal volume overload. No pleural effusions or pneumothorax are\n demonstrated.\n\n IMPRESSION: Focal areas of small patchy opacities, most likely due to\n atypical bacterial infection or viral pneumonia. Volume overload cannot be\n excluded.\n\n" }, { "category": "ECG", "chartdate": "2196-06-30 00:00:00.000", "description": "Report", "row_id": 130081, "text": "Sinus rhythm. Within normal limits. Compared to the previous tracing of \nno significant diagnostic change\n\n" }, { "category": "ECG", "chartdate": "2196-06-28 00:00:00.000", "description": "Report", "row_id": 130082, "text": "Sinus rhythm. Generalized low QRS voltage. Otherwise, there are no other\nsignificant diagnostic abnormalities. Compared to the previous tracing\nof no significant diagnostic change.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-07-01 00:00:00.000", "description": "Report", "row_id": 1270094, "text": " 4 ICU NPN 0700-1900\nCAlled out. No bed.\nUsing insulin pump Followed by MD's. Per pt, docter decreased basal rate between the hours of and MN. Appitite excellent. Bolus insulin via pump based on BS and carbohydrates consumed with meals. Insulin cartridge reloaded by RN.\nSlept in naps. No sz activity noted.\nVSS.\n Mom & roomate phoned & were updated on pt's condition & POC.\nA/P;\nStable. Update Nursing transfer note prior transfer to floor. Cont to assess BS. clinic to follow.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-06-30 00:00:00.000", "description": "Report", "row_id": 1270090, "text": "MICU NPN Admit to 4 from 11R:\n43y.o. female found unresponsive on 11R this morning and felt to have had possible hypoglcemic seizure.\n\nPMH: IDDM for 31yrs, GERD, constipation, failed transplant times two, pseudo seizure disorder, schizoeffective DO, bipolar disease, catatonic drpression, ADHDhypothyroidism, foot drop with right foot brace for walking, gastroparesis\n\nAllergies: Compazine, codeine, benzo's\n\nPt was admitted on for N/V/inability to eat after having the capsule study done in GI suite. Admitted for observation and has had multiple complaints since admission of gas, abdominal distension, right flank pain. Overnight she had been given mophine SQ (she lost IV access and was not able to get IV in place) and then complained of itching all over. She was then given benadryl for the itchiness. Her glucose this AM was 275 before breakfast and she gave herself 3.1units reg insulin via her pump. She was alert at 9AM and took all her AM meds. At 10AM she was seen by medical team and was unresponsive. BP 150/70, good sat Fingerstick was 62. Access was obtained and pt given d50w then d5w was hung. Pt was seen twitching ?seizure and ?breathing. Code was called and IV found to be infiltrated and femoral line was placed. Pt woke somewhat and transported to MICU for further care.\n\nLeft arm infiltrate elevated and cold compress applied but pt felf it to be too heavy. Pharmacy called and treatment for d50 infiltrate initiated. Elevate extremitiy. Cold or warm compress as tolerated and medical team instilled hyaluronidase around infiltrate site.\n\nNeuro: Pt awake and alert with many complaints which make it difficult to tell which ones are more serious than the other. MAE and follows commands. She has spastic movements with episodes of calling out at times but is able to stop and have a conversation and is able to stop them to eat. Cooperative with care and pleasant. Oriented times three but says she is confused. She thought it was the middle of the night once but oriented easily. Still has complaints of right flank pain but has not needed any meds for it yet.\n\nCV: BP 100-140/60. HR 70's NSR. Has left groin femoral line in place.EKG normal.\n\nResp: Came to us on 100% NRB but quickly weaned to 2L N/C and the off. Lungs clear with decreased sounds at bases. O2 sat 99% on RA.\n\nGI: Abdomen is distended and non tender passing flatus easily. Last BM Restarted diabetic diet at 1430. Only took small amts since she felt she might choke.\n\nGU: Voiding well on bedpan.\n\nEndocrine/diabetic: Titrating insulin drip according to blood glucose. Initially blood sugar was 379 and pt started on 1u/hr after 4 unit bolus. Pt's glucose dropped quickly and pt started on IV dextrose in IVF at 2PM. Will continue to check glucose Q1hr and titrate drip as needed with plans for to come by this afternoon and restart pt on her insulin pump.\n\nID: Given one dose of cefazolin because she was given groin line in code situation. Pt is afebrile. WBC 4.0. Two blood cultures sent as ordered.\n\nIV: Pt has groin\n" }, { "category": "Nursing/other", "chartdate": "2196-06-30 00:00:00.000", "description": "Report", "row_id": 1270091, "text": "MICU NPN Admit to 4 from 11R:\n(Continued)\n line and IVT will try to get access so we can try to take the groin line out tonight.\n\nPlease follow condition of infiltrate in left arm. Follow glucose Q1hr. Pt to restart insulin pump. Labs to be drawn at 3PM.\n" }, { "category": "Nursing/other", "chartdate": "2196-06-30 00:00:00.000", "description": "Report", "row_id": 1270092, "text": "MICU NPN Update:\n doctors came by and pt on her insulin pump at 1730. At 1830 I stopped the IV insulin as ordered and she was kep NPO for a few hours to make sure her glucose pump was working. She had stable glucose and was on her diet at 8PM and frequent blood sugars are to be followed tonight to make sure she remains stable. Her BP dropped into high 80's at 1800 and she was bolused with total 1000cc's NS over three hours which she tolerated well.\n\nPt continues to nod off to sleep at times and has waxing and mental status. She is alert and oriented times three. She seems to be using her pump appropriately and inputs all the data as she should be doing. She has not required any meds for pain. She has tylenol ordered PRN.\n\nVital signs are stable. Pt now off her O2. Will most likely get called out to the floor tomorrow. ?etiology of unresponsiveness. Best guess is her glucose control. Please follow closely tonight.\n\nPt's access will need to be changed before the floor can accept her. She remains with the groin line only. Site was oozing blood all shift and dressing changed twice. IVT was not able to get peripheral line into her. Two IV nurses tried.\n" }, { "category": "Nursing/other", "chartdate": "2196-07-01 00:00:00.000", "description": "Report", "row_id": 1270093, "text": "npn 23:00-07:00 (please also see carevue flownotes for objective data)\n\ndx: unresponsiveness/hypoglycemia, ?sz\n\n43F w/ mult med problems, admitted for capsule endoscopy as part of w/u for anemia; a.m. ate breakfast, took pills, was fine at 09:00; gave self bolus insulin from pump d/t FS's in 200's; at 10:00 found unresponsive by MDs, ?sz; FA 61 at that time, received IV transferred to 4 ICU for continued care;\n Insulin pump stopped; pt on Insulin gtt untill approx 17:30, at which was in and Insulin pump;\n FS's remained in acceptable range, until 23:00 was abit low at 67, started on IVF's D5NS at that time, FS's this night have settled in low 120's;\n\nPt very lethargic appearing/at interactions, however does focus on Ins pump when it beeps;\n\nVoided per pt request to use bedpan, raised own hips for bedpan; voided 800 cc's clear light yellow urine;\n\nIV team unable to obtain PIV; team desired to d/c fem cvl if possible, since placed under code situation.\n\nPLAN:\n1) continue q1 hr FS's\n2) check a.m. labs\n3) further plan per a.m. rounds, psych assessment may be requested\n4) femoral cvl until PIV can be obtained\n" } ]

[ { "category": "Radiology", "chartdate": "2174-08-01 00:00:00.000", "description": "INITAL 2ND ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 874751, "text": " 7:03 AM\n UNI-LAT FEMORAL Clip # \n Reason: possible angioplasty / stent ( to do )\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * PTA TIBIOPERONEAL & BRANCHES INITAL 2ND ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY PTA PERIPHEREAL ARTERY *\n * EXT UNILAT A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * CATH, TRANSLUM ANGIO NONLASER C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with NON HEALING ULCER /DR TO DO\n REASON FOR THIS EXAMINATION:\n possible angioplasty / stent ( to do )\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Infected right heel wound/non-healing ulcer, S/P\n right common femoral artery to plantar artery bypass graft.\n\n POSTOPERATIVE DIAGNOSIS: Same\n\n SURGEON: \n\n ASSISTANT: \n\n ANESTHESIA: Local with sedation\n\n FLUOROSCOPY TIME: 11.2 minutes.\n\n BASELINE CREATININE: 3.4\n CONTRAST: 60 cc of full strength Visipaque.\n\n PROCEDURE: Right lower extremity arteriogram via right common femoral artery\n approach, angioplasty of the plantar artery with a 2 x 4 angioplasty balloon,\n completion arteriogram.\n\n PROCEDURE AND DETAIL: The patient was brought to the interventional suite and\n placed in a supine position. After adequate sedation per nursing she was\n prepped and draped in the normal sterile manner. Antegrade right common\n femoral artery access was obtained using a 19 gauge single wall puncture\n needle, a 0.035 starter wire, and a 4 FR sheath. The wire was easily advanced\n into the common femoral artery and the wire was then directed into the bypass\n graft over this wire was placed the 4 FR sheath. The wire was advanced down\n through the bypass graft and the patient was systemically heparinized with\n 3000 units of intravenous heparin. The angle glide catheter was placed over\n the angle glide wire and placed in the distal bypass graft just above the\n posterior tibial artery an arteriogram was obtained. This demonstrated that\n there was an 80% stenosis just distal to the distal anastomosis and this was\n (Over)\n\n 7:03 AM\n UNI-LAT FEMORAL Clip # \n Reason: possible angioplasty / stent ( to do )\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n angioplastied with a 2 x 4 angioplasty balloon after systemically heparinizing\n the patient. A completion arteriogram demonstrated an improved result with no\n evidence of thrombosis or dissection. After an ACT was checked and found to\n be less than 200, all catheters wires and sheaths were removed and the access\n site was sealed with direct pressure. The patient tolerated the procedure\n well and was taken to the postoperative anesthesia care unit in stable\n condition. Dr. was present and scrubbed for the entire procedure and\n fluoroscopy was utilized.\n\n ANGIOGRAPHIC FINDINGS: There was a widely patent common femoral artery\n profunda femoris and SFA as well as a widely patent bypass graft to proximal\n anastomosis. There is a mild stenosis at the distal anastomosis of the bypass\n graft. We see angioplasty of the distal stenosis and after cannulation of the\n graft and this was done with a 2 x 4 angioplasty balloon completion\n arteriogram demonstrated an improved result with no thrombosis or dissection\n and excellent forward flow.\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-08-01 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 874798, "text": " 11:49 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs PICC / IV AB / has been evaluated - can not place beds\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with PVD needs PICC\n REASON FOR THIS EXAMINATION:\n Needs PICC / IV AB / has been evaluated - can not place bedside\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Peripheral vascular disease, needs IV antibiotics.\n\n PROCEDURE: The procedure was performed by doctors and , with Dr.\n , the Attending Radiologist, being present and supervising. The left\n upper arm was prepped in a sterile fashion. Since no suitable veins were\n visible, ultrasound was used for localization of a suitable vein. The left\n brachial vein was patent and compressible. After local anesthesia with 2 mL\n of 1% lidocaine, the basilic vein was entered under ultrasonographic guidance\n with a 21-gauge needle. Hard copies of ultrasound images were obtained,\n documenting patent vein before and after establishing an access. A 0.018\n guidewire was advanced under fluoroscopy into the superior vena cava. Based\n on the markers on the guidewire, it was determined that a length of 40 cm\n would be suitable. The PICC line was trimmed to length and advanced over a 4\n French introducer sheath under fluoroscopic guidance into the superior vena\n cava. The sheath was removed. The catheter was flushed. A final spot chest\n fluoroscopic image demonstrates the tip in the superior vena cava just above\n the right atrium. The line is ready for use. A statlock was applied and the\n line was heplocked.\n\n Complication: Oozing from the PICC punctures site occurred after the exam\n with hemostasis achieved via prolonged compression.\n\n IMPRESSION: Successful placement of a 40 cm total length PICC line with tip\n in the superior vena cava, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2174-07-01 00:00:00.000", "description": "MRA LOWER EXT W&W/O CONTRAST", "row_id": 871226, "text": " 4:21 PM\n MRA PELVIS W&W/O CONTRAST; MRA LOWER EXT W&W/O CONTRAST Clip # \n BILATERAL; MR CONTRAST GADOLIN\n Reason: MRA with gadolinium to eval aorta and LE vessels\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n Contrast: MAGNEVIST Amt: 30CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with long-standing DM, a/w diabetic ulcers and probable foot\n osteo. Need MRA WITH GADOLINIUM to eval aorta and LE vessels in anticipation\n for vascular intervention/revascularization.\n REASON FOR THIS EXAMINATION:\n MRA with gadolinium to eval aorta and LE vessels\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Longstanding diabetes mellitus with diabetic ulcers and probable\n foot osteomyelitis, potential candidate for revascularization.\n\n TECHNIQUE: Aorta and lower extremity MRA was performed. Time of flight and\n gadolinium enhanced 3D images were obtained using TRICKS sequence. Subtraction\n sequences were performed.\n\n MRA:\n There is irregularity of the abdominal aortic wall consistent with\n atherosclerotic disease. No significant stenoses are seen within the aorta\n and there is no aneurysmal dilatation but the infrarenal abdominal aorta\n shows a slight prominence. There is a suggestion of a calcified plaque at the\n origin of the left renal artery.\n\n RIGHT: There is diffuse mild wall irregularity of the right common and\n external iliac arteries without stenosis. There is a short segment focal (7\n mm) high- grade stenosis in the left external iliac. The left common iliac and\n the left external iliac, distal to the stenosis, are normal.\n\n In the right leg, there is diffuse disease of the superficial femoral artery\n with a high-grade focal narrowing in the mid superficial femoral artery. The\n above knee popliteal artery is moderately diffusely diseased. Several tandem\n high-grade stenoses are seen in the below knee popliteal artery. Geniculate\n collaterals are present. No definite flow is seen at the origins of the three\n vessels in the calf. Extensive collaterals are present in the upper calf.\n There is segmental reconstitution of the peroneal artery at its mid and lower\n portions. There is a distal collateral to the posterior tibial artery off of\n the peroneal. No significant flow is present within the anterior tibial or\n dorsalis pedis arteries.\n\n LEFT: In the left leg, there is diffuse disease in the superficial femoral\n artery. There is a short segment mild focal narrowing in the proximal left\n SFA. A high grade long segment stenosis is present in the distal superficial\n femoral artery, measuring 5.8 cm in length. Collaterals are present in this\n region. There is reconstitution of the above-knee popliteal. The below- knee\n popliteal artery shows mild diffuse disease but is patent. There is single\n vessel calf runoff via the peroneal artery. There is partial reconstitution\n at the ankle of a diseased dorsalis pedis artery. Reconstitution of the\n (Over)\n\n 4:21 PM\n MRA PELVIS W&W/O CONTRAST; MRA LOWER EXT W&W/O CONTRAST Clip # \n BILATERAL; MR CONTRAST GADOLIN\n Reason: MRA with gadolinium to eval aorta and LE vessels\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n Contrast: MAGNEVIST Amt: 30CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n plantar arch at the ankle is also demonstrated through collaterals to the\n PT from the peroneal artery.\n\n IMPRESSION:\n\n Extensive disease with limited distal runoff. Tibial vasculature is more\n robust on the left vs. the right.\n\n KEYWORD: VASCULAR\n\n\n\n" }, { "category": "Echo", "chartdate": "2174-06-28 00:00:00.000", "description": "Report", "row_id": 102163, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nHeight: (in) 50\nWeight (lb): 100\nBSA (m2): 1.22 m2\nBP (mm Hg): 128/70\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 12:46\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate global LV\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is moderate global left ventricular\nhypokinesis. Right ventricular chamber size and free wall motion are normal.\nThe ascending aorta is mildly dilated. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with moderate global\nhypokinesis. Mild mitral regurgitation.\nIn the absence of a history of systemic hypertension, an infiltrative process\n(e.g., amyloid) should be considered.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-08-03 00:00:00.000", "description": "MR CONTRAST GADOLIN", "row_id": 875040, "text": " 10:41 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please eval 3 lesions seen on CT--infarct vs mass. page \n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with slurred speech, qwestion of infarcts vs masses on CT.\n REASON FOR THIS EXAMINATION:\n please eval 3 lesions seen on CT--infarct vs mass. page w/\n questions/results. thanks.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n MRI SCAN OF THE BRAIN WITH GADOLINIUM ENHANCEMENT\n\n HISTORY: Slurred speech. Question of infarct versus mass on CT.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained\n including the use of diffusion-weighted imaging.\n\n FINDINGS: Unfortunately, all but the diffusion-weighted images are of\n extremely limited resolution due to gross patient motion.\n\n There is a 1 cm linear area of slightly elevated signal on the diffusion-\n weighted images in the right frontal lobe, which likely has corresponding\n elevated signal on FLAIR scans. Therefore, this finding could represent an\n area of subacute infarction. The low-density areas seen on CT are represented\n by somewhat more extensive zones of elevated T2 signal within the white matter\n of both cerebral hemispheres, with some extension towards the right occipital\n lobe cortex. The gadolinium-enhanced images are nearly uninterpretable due to\n gross motion artifact. Within the very severe limitations imposed by these\n poor quality scans, no obvious enhancement is seen to suggest a tumor mass,\n but extreme caution must be exercised regarding the validity of these\n interpretations. If there truly is no enhancement, the signal intensity\n abnormalities likely represent areas of small vessel infarction. There is no\n hydrocephalus or shift of normally midline structures. There are probable\n scattered tiny foci of susceptibility largely within the cortical regions of\n both cerebral hemispheres, most evident in the temporal lobes. As there are\n no calcifications seen on the prior CT, presumably they represent tiny\n hemorrhagic residues from prior infarcts. No obvious abnormality of the\n circle of vasculature is seen, again allowing for very poor image\n resolution. There is mild mucosal thickening within the ethmoid and sphenoid\n sinuses, presumably an allergic or some other type of inflammatory process.\n\n CONCLUSION: Virtually uninterpretable study due to gross patient motion. No\n obvious areas of enhancement seen to suggest neoplastic disease involving the\n brain.\n\n" }, { "category": "Radiology", "chartdate": "2174-08-05 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 875379, "text": " 2:37 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Assess position of Quintin catheter, in Right IJ\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with feeding tube with increased somnolence, difficulty\n to arouse and WBC up to 19 this am\n REASON FOR THIS EXAMINATION:\n Assess position of Quintin catheter, in Right IJ\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Right IJ Quinton catheter placement.\n\n There has been interval placement of a right internal jugular Quinton\n catheter. Although the most distal tip is obscured by an overlying external\n monitoring lead, the catheter does appear to terminate within the superior\n vena cava. The left PICC line and feeding tube remain in place. The lung\n volumes are slightly increased compared to the recent study with improving\n aeration in the lung bases. There is otherwise no significant change since\n the recent study of earlier the same date, and there is no evidence of\n pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-06 00:00:00.000", "description": "Report", "row_id": 1320273, "text": "see careview for details.\nabd u/s done. pt received 2 u ffp, 1 u platelets, followed by an unsuccessful series of attempts to place a cholesystotomy tube.\nvital signs unstable. hypothermia treated with bair hugger, returned to 98-97. heart rhythm nsr with occasional pvc's, pac's. drifed to sinus bradycardia with extremely low bp. levophed maxed at .5-.6 mcg/kg/.,several boluses of LR given. vasopressin added at max dosage. tx with epinephrine with temporary response. epi repeated with similar response. family called to report gravity of pt's condition, they returned to bedside where they decided not to have pt undergo surgery, as she was an extremely poor candidate and high risk. priest called. pt expired with family present at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-05 00:00:00.000", "description": "Report", "row_id": 1320272, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt transferred from 9 d/t hypotension and decrease in mental status. Pt opens eyes to voice; pt is legally blind. + corneal reflex. Slightly withdraws all extremities when nailbed pinched. Nonpurposeful spont movement at times. PERRLA (3mm; sluggish). Does not follow commands. Facial twitching noted at 1900; lasted for approx 1minute (Dr. and Dr. aware). Pt does not appear to be in discomfort. No grimacing noted. Pt's temp 95-96F. Bair-Hugger placed on pt. HR 60-90s (NSR w/ occasional PVCs). A-line very difficult to place. Upon arrival to SICU, SBP 80-90s. Levo gtt started to keep MAP>65 and SBP>95 (w/ +effect). LR 500cc IVBx1 per Dr. . + edema. Right DP/PT/graft pulses weakly palpable. Left DP/PT dopplerable. Right BPG incision w/ steristrips open to air; dry and intact. Upper thigh covered w/ DSD d/t small amount serous drainage. Right heel w/ VAC dsg (@ 125mmHg suction w/ scant amount serosang drainage). O2 sat WNL on 2LNC. Lungs diminished, + crackles at bases. No cough noted. ABG showed metabolic acidosis. Abdomen softly distended w/ +BS. Pedi tube in right nare; clamped at this time. Per Dr. , hold TF. Pt anuric. Plan was to HD this afternoon, but dialysis stopped after 15minutes d/t low BP. ?CVVH tonight. Foley intact. son, daughter, and daughter-in-law in to visit; updated w/ plan of care.\n Plan: Pt is DNR/DNI. US of liver/gallbladder ordered. Cont to monitor neuro/resp status, VS, I's and O's. CVVH tonight. Titrate Levo gtt to keep MAP>65 and SBP>95. Replete lytes prn. Notify HO w/ any changes. Update family w/ plan of care. Cont ICU care and treatment.\n" }, { "category": "Radiology", "chartdate": "2174-08-06 00:00:00.000", "description": "GUIDANCE PERC TRANS BIL DRAINAGE US", "row_id": 875429, "text": " 12:37 AM\n GB DRAINAGE,INTRO PERC TRANHEP BIL US PORT; GUIDANCE PERC TRANS BIL DRAINAGE USClip # \n Reason: acute cholecystitis in septic pt in icu. please place perc\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with PVD, sepsis, ARF\n REASON FOR THIS EXAMINATION:\n acute cholecystitis in septic pt in icu. please place perc chole tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Septic patient with suspected cholecystitis clinically and by\n ultrasound.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , the attending radiologist,\n was present for the entire procedure.\n\n DESCRIPTION OF PROCEDURE: The procedure, its indications, risk, benefits and\n alternatives were discussed at length with the patient's daughter-in-law,\n . Verbal consent was obtained by telephone. A preprocedure\n timeout was performed. The patient was prepped and draped in sterile fashion.\n 1% lidocaine was used for local anesthesia.\n\n Initial limited ultrasound of the right upper quadrant demonstrated a\n distended gallbladder with wall thickening, as seen in the formal right upper\n quadrant ultrasound earlier in the day.\n\n There was no active patient cooperation with the procedure, and patient motion\n made the procedure more difficult. Ultrasound guidance was used to place an\n 8- French catheter into the gallbladder, yielding bilious fluid by\n aspiration. After attempt at deployment of the catheter, there was irregular\n return of fluid suggestive of malposition. A second attempt was used using a\n TLA needle and guidewire. After successful aspiration of fluid, there was\n difficulty deploying the wire within the gallbladder lumen. A third attempt\n was made with a single stick technique using an 8-French catheter.\n While fluid was aspirated, this third attempt was also unsuccessful in\n deployment of the catheter and the catheter coiled in adjacent ascites.\n\n Some of the bilious fluid was sent to the lab for analysis. The technical\n challenges of this procedure including patient motion and inability to keep\n the catheter deployed within the gallbladder lumen were discussed with the\n surgical services caring for the patient. At this time, it was decided to\n await results of the fluid analysis and then clinically decide whether\n additional intervention is needed. There were no immediate complications to\n the procedure, although the patient's blood pressure remained relatively low\n throughout the procedure.\n\n No images were obtained. The study was performed portably on an urgent basis.\n\n IMPRESSION: Technically unsuccessful percutaneous cholecystostomy placement\n under ultrasound guidance.\n\n\n (Over)\n\n 12:37 AM\n GB DRAINAGE,INTRO PERC TRANHEP BIL US PORT; GUIDANCE PERC TRANS BIL DRAINAGE USClip # \n Reason: acute cholecystitis in septic pt in icu. please place perc\n Admitting Diagnosis: HYPAGLYCEMIA, FOOT ULCER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2174-08-05 00:00:00.000", "description": "Report", "row_id": 296130, "text": "Sinus rhythm. Short P-R interval. Since the previous tracing of \nprobably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2174-08-02 00:00:00.000", "description": "Report", "row_id": 296131, "text": "Sinus rhythm\nLow amplitude T waves - are nonspecific but clinical correlation is suggested\nSince previous tracing of , QRS voltages less prominent and ST-T wave\nchanges decreased\n\n" }, { "category": "ECG", "chartdate": "2174-06-26 00:00:00.000", "description": "Report", "row_id": 296132, "text": "Artifact in leads I and III. Sinus rhythm. Left ventricular hypertrophy. Left\natrial enlargement. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2142-07-15 00:00:00.000", "description": "Report", "row_id": 135387, "text": "Sinus rhythm. Broad P waves. Axis to the left. Low amplitude T waves in\nleads I and aVL. T wave inversion in leads V3-V4. Flat T waves in leads V5-V6.\nINT: Non-specific T wave abnormalities. Left axis deviation. Compared to the\nprevious tracing of ventricular ectopy is no longer present. T wave\ninversions are also no longer present in leads V4-V5. Left axis deviation has\nappeared.\n\n" }, { "category": "Radiology", "chartdate": "2142-08-03 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 742751, "text": " 9:53 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: 77 y.o. woman with metastatic RCC. NG tube reinserted due t\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n renal ca with mets to lung requirng longterm iv antibx.\n REASON FOR THIS EXAMINATION:\n 77 y.o. woman with metastatic RCC. NG tube reinserted due to coiling in the\n mouth. Need to check if NG tube is in the stomach before starting tube feeds.\n Please call H.O. with results. Pager , Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n CXR, :\n\n CLINICAL: Check NGT placement.\n\n FINDINGS: A single AP portable exam reveals a NGT which extends well below\n the diaphragms, although the exam does not reveal the tip itself. The\n remainder of the exam is unchanged from the comparison, including the\n pulmonary edema and bibasilar atelectasis +/- effusion.\n\n IMPRESSION: 1) NGT in satisfactory position. 2) Otherwise, no interval\n change from .\n\n" }, { "category": "Radiology", "chartdate": "2142-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 742186, "text": " 4:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? chf/pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell ca to lungs s/p hemoptysis and RLL\n argon coag treatment for bleed.\n REASON FOR THIS EXAMINATION:\n ? chf/pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE RADIOGRAPH OF THE CHEST:\n\n INDICATION: History of renal cell carcinoma metastatic to the lung with\n hemoptysis, evaluate for pulmonary edema.\n\n COMPARISON: AP portable radiograph of the chest dated .\n\n FINDINGS: The heart is stably enlarged. There is slightly decreased perihilar\n and right lower lobe opacification. There is somewhat increased opacification\n involving the left lower lobe with blunting of the left costophrenic angle.\n Patient is s/p extubation. An NG tube is seen with its tip in the proximal\n stomach. Soft tissue and osseous structures are otherwise unremarkable.\n\n IMPRESSION: 1) Slightly decreased perihilar haziness, which may reflect\n improving pulmonary edema .\n 2) Worsening left pleural effusion and adjacent lung opacity,\n likely atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2142-08-08 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 743004, "text": " 12:38 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Please evaluate for continued aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA, admitted with hemptyosis -\n intubated x 2; s/p stenting of L main stem bronchus and bronchus intermedius;\n NGT with TF; evaluate for aspiration\n REASON FOR THIS EXAMINATION:\n Please evaluate for continued aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic renal cell carcinoma, aspiration on prior swallowing\n study.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was performed with the speech\n therapist. Multiple consistencies of barium were administered. Oropharyngeal\n transit is normal. There is moderate volecular residue with laryngeal\n penetration with all consistencies. There is aspiration with paste and thin\n liquids.\n\n IMPRESSION:\n 1) Aspiration with thin liquids and paste consistencies.\n 2) Volecular residue and laryngeal penetration with all consistencies.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-29 00:00:00.000", "description": "P CHEST (SINGLE VIEW) PORT", "row_id": 742443, "text": " 10:40 PM\n CHEST (SINGLE VIEW) PORT Clip # \n Reason: please confirm picc tip placement to right arm ; page \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with\n renal ca with mets to lung requirng longterm iv antibx.\n REASON FOR THIS EXAMINATION:\n please confirm picc tip placement to right arm ; page with results.\n thanks... pt is mrsa\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP VIEW.\n\n The distal end of PICC line is difficult to accurately localize on this film,\n but could extend into the upper right atrium. NG tube extends below the\n diaphragm. There are probable bilateral pleural effusions and bibasilar\n atelectases. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-07-30 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 742470, "text": " 10:56 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: evalautefor aspirationrisk\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA, admitted with hemptyosis -\n intubated x 2; s/p stenting of L main stem bronchus and bronchus intermedius;\n NGT with TF; evaluate for aspiration\n REASON FOR THIS EXAMINATION:\n evalautefor aspirationrisk\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic renal cell carcinoma, intubated x 2. Status post\n stenting of left main stem bronchus and bronchus intermedius. NG tube with\n tube feeds.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was performed with the speech\n therapist. Multiple consistencies of barium were given. Oral pharyngeal\n transit was normal. With paste consistency, there is mild to moderate\n vallecular residue with laryngeal penetration in the pharyngeal stage and\n absent epiglottic deflection. There is valleulcar residue on all\n consistencies.\n\n Aspiration on thin liquids is demonstrated which initiated a spontaneous cough\n and cleared the aspirates.\n\n IMPRESSION:\n 1. Aspiration of thin liquid with spontaneous coughing.\n 2. Vallecular residue of all consistencies with laryngeal penetration on paste\n consistency.\n\n" }, { "category": "Radiology", "chartdate": "2142-08-09 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 743075, "text": " 2:34 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place percutaneous gastric/duodenal feeding tube\n Contrast: OPTIRAY Amt: 30CC\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE *\n * -59 DISTINCT PROCEDURAL SERVICE PERC PLCMT ENTROCLYSIS TUBE *\n * IV CONSCIOUTIOUS SEDATION PRO NON-IONIC 30 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal carcinoma admitted with hemoptysis -\n intubated; bronchoscopy with stenting of L main bronchus and bronchus\n intermedius; now with NGT - failed speech and swallow study x ; needs PEGJ\n placement;\n REASON FOR THIS EXAMINATION:\n Please place percutaneous gastric/duodenal feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 year old woman with metastatic renal cell carcinoma and recurrent\n aspiration.\n\n RADIOLOGISTS: Drs. and . The attending\n radiologist, Dr. , was present for the entire procedure.\n\n TECHNIQUE: The procedure, indications, risks and benefits were discussed with\n the patient, and written consent was obtained. The patient was positioned\n supine on the angiography table, and the epigastrium was prepped and draped in\n sterile fashion. The colon was previously opacified with oral contrast and\n the stomach was insufflated with air. Fluoroscopic examination was performed\n to determine an appropriate puncture site. Limited ultrasound exam was\n performed to exclude the presence of intervening hepatic parenchyma.\n\n The skin entry site was locally anesthesized with 1% lidocaine. Three T-\n fasteners were placed under fluoroscopic guidance. Positioning of each T-\n fastener within the stomach was confirmed by injection of contrast prior to\n deployment. With the T-fasteners secured, a needle was passed into the\n stomach and guide wire was advanced into the antrum. The needle was\n then exchanged for a 5 FR vascular sheath. A 5 FR veretebral catheter and the\n wire were used to manuever through the antrum and pylorus and into the\n duodenum. The vertebral catheter was not of sufficient length to be advanced\n beyond the duodenum and was exchanged for a 5 FR multipurpose catheter. This\n was placed over the guide wire into the proximal jejunum. The wire\n was then exchanged for an Amplatz guide wire, and the catheter and sheath were\n removed.\n\n The percutaneous tract was then prepared with 6, 8 and 12 FR dilators, and a\n 14 FR peelaway sheath was placed. A 14 FR gastrojejunostomy tube was\n then placed through the sheath and over the wire without difficulty. The\n sheath and wire were removed, and the interlocking loop of the tube was formed\n within the descending portion of the duodenum. Contrast was injected to\n confirm appropriate placement of the tube tip. The patient tolerated the\n procedure well.\n (Over)\n\n 2:34 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: Please place percutaneous gastric/duodenal feeding tube\n Contrast: OPTIRAY Amt: 30CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CONTRAST: 30 mL Optiray 320. Nonionic contrast used due to allergies.\n\n ANESTHESIA: 1% lidocaine given locally. 0.625 mg droperidol was given as an\n antiemetic. 50 mg fentanyl was given intravenously in divided doses under\n continuous hemodynamic monitoring for conscious sedation.\n\n COMPLICATIONS: There were no immediate complications.\n\n FINDINGS: An abdominal radiograph obtained after the procedure demonstrates\n the interlocking loop within the descending duodenum and the feeding tube tip\n in the proximal jejunum. Ultrasound of the puncture site did not demonstrate\n underlying hepatic parenchyma.\n\n IMPRESSION: Successful placement of 14 FR gastrojejunostomy tube.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2142-08-03 00:00:00.000", "description": "REPOSITION GASTRIC TUBE INTO DUODENUM", "row_id": 742735, "text": " 3:13 PM\n REPOSITION GASTRIC TUBE INTO DUODENUM Clip # \n Reason: Please place a nasal-duodenal feeding tube.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell cancer and hemoptysis now\n aspirating. Attending would prefer nasal feeding tube rather than PEG at this\n time.\n REASON FOR THIS EXAMINATION:\n Please place a nasal-duodenal feeding tube.\n ______________________________________________________________________________\n FINAL REPORT\n FLUOROSCOPIC GUIDED POST PYLORIC FEEDING TUBE PLACEMENT:\n\n INDICATION: Hemoptysis, aspirating. Metastatic renal cell cancer.\n\n An 8 French feeding tube was positioned through the right nostril into the\n patient's mid duodenum. The position was verified under fluoroscopy using\n Gastrografin. It was not possible to further advance the feeding tube. The\n patient tolerated the procedure with no immediate complication.\n\n Dr. supervised this procedure.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741790, "text": " 9:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrates s/p bronchoscopy\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA (to the lungs) with\n hemoptysis and partial airway obstruction from tumur met to lung, now s/p\n bronchoscopy with stents to bronchus intermedius and L main.\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrates s/p bronchoscopy\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Metastatic renal cell CA to the lungs. Hemoptysis and partial\n airway obstruction from tumor metastases. S/P bronchoscopy with stent\n placement. Assess for infiltrates following bronchoscopy.\n\n FINDINGS: A single AP upright chest film is provided. This is compared with\n the prior study of the previous day. There has been re-expansion of the\n previously collapsed right lower lobe with restoration of the right diaphragm\n to its normal position. An ovoid right lower lobe mass is again demonstrated\n in the lower zones medially. No other definite pulmonary masses are\n identified. There is blunting of the right costophrenic angle consistent with\n a small effusion. Minimal blunting may also be present on the left side. The\n heart shows some LV enlargement and the aorta is dilated and unfolded. The ETT\n remains in satisfactory position. The NG tube extends well below the left\n diaphragm.\n\n A new wallstent has been inserted in the left main bronchus and its tip has\n entered the left upper lobe bronchus. The lumen appears of good caliber in the\n stented region.\n\n IMPRESSION: 1) Re-expansion of right lower lobe. Right lower lobe nodule\n visualized. 2) The stent is visible in the left main bronchus and left upper\n lobe bronchus.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741896, "text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt S/P intubation. Please evaluate ETT position.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA (to the lungs) with\n hemoptysis and partial airway obstruction from tumur met to lung, now s/p\n bronchoscopy with stents to bronchus intermedius and L main. Now w/ increasing\n cough, purulent sputum.\n REASON FOR THIS EXAMINATION:\n Pt S/P intubation. Please evaluate ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Evaluation of ET tube position in patient with metastatic renal cell\n cancer and hemoptysis, bronchoscopy.\n\n ET tube is 2.7 cm above carina. NG tube is in proximal stomach. Heart size\n is borderline for technique. No evidence for CHF. There are ill-defined\n patchy opacities in the right apical region, aa well as the right lung base\n with a small right pleural effusion, probably unchanged from previous film of\n , if allowance is made for significant technical differences. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741965, "text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt w/ hemoptysis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with ca, recent hemoptysis\n REASON FOR THIS EXAMINATION:\n pt w/ hemoptysis\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Cancer and recent hemoptysis.\n\n ET tube is 3 cm above carina with the neck flexed. NG tube extends below\n diaphragm. Heart size is borderline for technique. No evidence for CHF.\n There is persistent opacity at the right base, probably due to a combination\n of consolidation and small pleural effusion. The remainder of the lungs are\n grossly clear in this limited single view.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 742005, "text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt w/ h/o renal cell ca to lungs, hemoptysis 2 days ago.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with renal cell CA to lungs; trnasferred to MICU w/\n hemoptysis; reintubated .\n REASON FOR THIS EXAMINATION:\n pt w/ h/o renal cell ca to lungs, hemoptysis 2 days ago.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE FILM\n\n HISTORY: Metastatic renal cell cancer with hemoptysis and intubation.\n\n Endotracheal tube is 3 cm above carina. NG tube extends below diaphragm. No\n pneumothorax. Compared with the previous film of there has been some\n further clearing of the opacity at the right lung base. There is persistent\n blunting of the right costophrenic angle and probable atelectasis at the right\n lung base. Apart from linear atelectases in the left lower zone the left lung\n is clear.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741868, "text": " 2:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for new infiltrates or effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA (to the lungs) with\n hemoptysis and partial airway obstruction from tumur met to lung, now s/p\n bronchoscopy with stents to bronchus intermedius and L main. Now w/ increasing\n cough, purulent sputum.\n REASON FOR THIS EXAMINATION:\n please assess for new infiltrates or effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: METASTATIC RENAL CELL CARCINOMA WITH HEMOPTYSIS. ASSESS FOR NEW\n INFILTRATES OR EFFUSIONS SOMEWHAT UNDERPENETRATED CHEST.\n\n The cardiac size is within normal limits. The left lung field is clear.\n There has been further clearing of the right lower lobe. No new infiltrates\n are present.\n\n IMPRESSION: Further re-expansion and clearing of right lower lobe. No new\n infiltrate.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741725, "text": " 8:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt coughing frank blood this AM.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA (to the lungs) now with\n hemoptysis and partial airway obstruction from tumur met to lung.\n REASON FOR THIS EXAMINATION:\n Pt coughing frank blood this AM.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE\n\n INDICATION: Hx of metastatic renal cell carcinoma with new hemoptysis.\n Evaluate for airway obstruction.\n\n COMPARISONS: AP portable chest .\n\n There has been interval loss of lung volume and collapse in all segments of\n the right lung. The previously seen mass in the right lung is now obscured by\n adjacent lung consolidation. The trachea and mediastinal contents are\n deviated to the right side consistent with loss of volume. There appears to be\n slightly increased density within the lumen of the right main stem bronchus.\n There has been interval intubation of this patient. The ET tube tip lies\n approximately 1.5 cm above the carina. NG tube tip lies in the stomach. The\n left lung is clear without evidence of focal pulmonary opacities or focal\n pleural effusions.\n\n IMPRESSION:\n\n 1. Interval collapse of right lung segments. There is increased density seen\n within the lumen of right main stem bronchus possibly representing blood. The\n ET tube and NG tube are in good position.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741667, "text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt admitted for hemoptysis and partial airway obstruction fr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with metastatic renal cell CA (to the lungs) now with\n hemoptysis.\n REASON FOR THIS EXAMINATION:\n Pt admitted for hemoptysis and partial airway obstruction from tumor. Please\n evaluate for changes since last night's CXR. Brochoscopy for today.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of metastatic renal cell cancer with new hemoptysis,\n evaluate for airway obstruction from tumor.\n\n COMPARISONS: PA & lateral radiograph of the chest dated .\n\n FINDINGS: Again seen is the right lower lobe mass, unchanged from the prior\n study. This mass is irregular with a spiculated border and adjacent\n atelectasis. The heart size is difficult to assess given the low lung volumes.\n The aorta is slightly unfolded. Again seen are the bilateral hilar adenopathy.\n Slight prominence of the upper lung vasculature. The osseous structures are\n unremarkable.\n\n IMPRESSION: 1) Right lower lobe mass with hilar adenopathy, unchanged. This is\n consistent with the given history of metastatic renal cell carcinoma. 2)\n Slight prominence of the upper lung vasculature when compared with the prior\n study. There may be a component of mild CHF.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-15 00:00:00.000", "description": "CHEST CTA WITH CONTRAST", "row_id": 741647, "text": " 8:21 PM\n CHEST CTA WITH CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n Reason: eval mass lesion, look for PE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with renal cell cancer, mets to lung presenting with sob,\n hemoptysis\n REASON FOR THIS EXAMINATION:\n eval mass lesion, look for PE\n ______________________________________________________________________________\n FINAL REPORT\n CT PA-GRAM.\n\n HISTORY: 77 year old female with renal cell cancer with lung mets with\n shortness of breath and hemoptysis.\n\n TECHNIQUE: Contiguous helical images of the thorax were obtained after the\n administration of 100 cc of intravenous Optiray. Optiray was used per the\n fast bolus of the CTPA protocol.\n\n COMPARISON: .\n\n CT THORAX WITH IV CONTRAST: There are no filling defects within the main\n pulmonary arteries and visualized tributaries.\n\n There has been marked progression of the right infrahilar mass and subcarinal\n and hilar lymphadenopathy. This results in compression of the right and left\n main stem bronchi and severe compression of the bronchus intermedius. There\n is basilar atelectasis. A mosaic pattern of the parenchyma, right greater\n than left, may reflect air trapping.\n\n Bone windows demonstrate degenerative changes but no suspicious lytic or\n blastic lesions.\n\n IMPRESSION:\n\n 1) No evidence of pulmonary embolus.\n\n 2) Marked progression of bilateral infrahilar lung masses and subcarinal and\n bilateral hilar lymphadenopathy. There is resultant compression of the\n main stem bronchi bilaterally with severe compression of the bronchus\n intermedius.\n\n Findings were discussed with Dr. at the time of the exam.\n\n" }, { "category": "Radiology", "chartdate": "2142-07-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 741646, "text": " 7:31 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o mass lesion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with h/o renal cell cancer with mets to lung presenting with\n hemoptysis\n REASON FOR THIS EXAMINATION:\n r/o mass lesion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of renal cell cancer with metastases to the lungs\n presenting with hemoptysis.\n\n FINDINGS: Two views of chest. Comparison made with . As before,\n there is bilateral hilar adenopathy with a mass within the right lower lobe.\n There is obscuration of the left hemidiaphragm and relatively low lung\n volumes. There is no evidence of congestive heart failure, pleural effusions,\n or pneumothorax. There is diffuse osteopenia but no definite osseous lesions.\n\n IMPRESSION:\n\n 1) Right lower lobe mass. Compared with the prior study, this appears to be\n increased in size from prior study.\n\n 2) Bilateral hilar adenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-07-16 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 741705, "text": " 7:29 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: LT FACIAL PALSY,H/O CA\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with renal cell ca metastatic to lung, with L. facial palsy.\n REASON FOR THIS EXAMINATION:\n eval for brain metastases\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal cell cancer with left sided facial paulsy.\n\n Multiplanar T1 and T2 weighted images of the brain are obtained. T1 weighted\n coronal and axial images were performed before and after Gadolinium\n administration. Correlation is made to the CT examination from .\n\n Sagittal images reveal a large intrasellar soft tissue mass lesion which\n demonstrates suprasellar extension with superior displacement and compression\n of the optic chiasm. The mass enhances mostly homogeneously following\n Gadolinium administration and measures 2.8 cm in height and 2.7 cm in width.\n There is partial invasion of the cavernous sinuses bilaterally. Normal signal\n flow void is maintained within the intracavernous portions of the internal\n carotid arteries. There is deformity and expansion of the sella. Slight\n posterior parasellar extension is seen along the anterior prepontine cistern.\n Differential considerations would include a large pituitary macroadenoma or\n meningioma. Metastatic disease is less likely given the pattern of\n enhancement but not totally excluded.\n\n No intraparenchymal enhancing lesions could be demonstrated following\n Gadolinium administration. The posterior fossa structures are unremarkable\n and the fourth ventricle is in the midline. There is mild cortical atrophy.\n\n IMPRESSION: Large intrasellar soft tissue mass lesion with suprasellar\n extension, invasion of the cavernous sinuses, superior displacement and\n compression of the optic chiasm and homogeneous enhancement following contrast\n administration most likely representing a large pituitary macroadenoma.\n There is deformity and expansion of the sella and slight posterior\n retrosellar expansion. This would suggest the possibility of a less likely\n diagnosis of a menigioma. Metastatic disease would be very unlikely given\n the location and the nature of the enhancement but totally excluded. There\n is no mass effect on the brain parenchyma.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-21 00:00:00.000", "description": "Report", "row_id": 1501897, "text": "P-MICU NPN 0700-1900\n\nRESP: Weaned to IMV 6 w/spont RR 3-6. Stable ABG. Maintaining gd O2sats. Suct ~q2hrs for thick tannish sputum, occ bld-tinged and/or w/sm old clots. Given CPT to L side but became hypotensive on side. Has been on back most of day and CPT to R side not done.\n\nCV: Dopa weaned to 4mcgs. Tol for a few hours then MAP <60 w/sys BP 70-80s. Dopa currently back up to 7 mcgs. MAP 60s w/sys BP 90-100.\n\nFE: Cont w/gd urine output, >100cc/hr. Na 149 this am and NS changed to D.45NS at 100/hr.\n\nENDO: stim test pnd.\n\nNEURO: Propofol at 20mcgs. No changes made. Arousable but sleepy. Follows simple commands.\n\nNUTRITION: +bowel sds. promote w/fiber at 10cc/hr started. Goal is 50cc while she is on Propofol (mixed with lipids).\n" }, { "category": "Nursing/other", "chartdate": "2142-07-22 00:00:00.000", "description": "Report", "row_id": 1501898, "text": "RESP CARE,\nPT. REMAINS INTUBATED CURRENTLY ON SIMV 10/500/.4/5PEEP/IPS15. RR UNCREASED TO 10 OVERNOC TO REST. OVERBREATHING RR 14. SUCTIONED YELLOW SPUTUM. SEE VENT FLOWSHEET.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-22 00:00:00.000", "description": "Report", "row_id": 1501899, "text": "PMICU NURSING NOTE\nRESP: PT AWAKE AND UNCOMFORTABLE, COUGHING, REQUIRING FREQ SUX, SRR 8-10 OVER VENT. THEREFORE, CHANGED PT TO IMV 10 FOR THE NIGHT-TURNED FREQUENTY. SUX Q3H FOR MOD SECRETIONS-LG AMNT SUX FROM BACK OF THROAT\nNEURO: AWAKE MUCH OF NIGHT. STATING UNCOMFORTABLE-INCREASED PROPOFOL GTT SLIGHTLY-FINALLY ABLE TO SLEEP LATER IN MORNING\nGI: TOL TUBE FEEDS AT 20/HR. NO STOOL\nID: AFEBRILE. VANCO REORDERED B/C NOT AVAILABLE AT 4AM-\nCV: DOPA ADJUSTED PER BP-PT NOTED TO HAVE FREQUENT PVC'S EARLY IN NIGHT , NO C/O CHEST PAIN-REPLETED W/40MEQ KCL-CHECK AM LABS\nA: RESTLESS NIGHT\nP: INCREASED PROPOFOL FOR GOOD EFFECT-FOLLOW LABS AND ECTOPY\n" }, { "category": "Nursing/other", "chartdate": "2142-07-22 00:00:00.000", "description": "Report", "row_id": 1501900, "text": "P-MICU NPN 0700-1900\n\nSleeping on and off most of day. No change in Propofol gtt. Arousable and appropiate when awake. No vent changes. Suct Q3-4 for mod amt thick tan-yellow sputum. Less bloody than yesterday. Remians on Dopa. Attempts at weaning,from 4mcgs to off,despite 1L NS IVB,unsuccessful. Currently has NS at 250cc/hr and BP seems to be improving. Dopa currently at 3mcgs and she is tol well. Cont to volume rescusitate and wean Dopa as tol. TFs at goal. Minimal residuals. Also tolerating free water boluses. No stools as yet. Plan to cont TFs as tol. need to increase rate once off Propofol. Husband cld x2. Did not come into as he has a \"cold\".\n" }, { "category": "Nursing/other", "chartdate": "2142-07-23 00:00:00.000", "description": "Report", "row_id": 1501901, "text": "RESP CARE,\nPT. REMAINS INTUBATED SIMV 10/550/.4/5PEEP/IPS15. SUCTIONED YELLOW PLUGS, STARTED ON VENTOLIN MDI. NO VENT CHANGES THIS SHIFT.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-27 00:00:00.000", "description": "Report", "row_id": 1501915, "text": "NPN 7p-7a\n\nPt. stable overnoc.\n\nReview of Systems:\n\n Pt. remains neurologically intact. A+O X3; pleasant. Pt. denied pain/ discomfort overnoc.\n\n Pt. maintained sat's above 96% on 4L NC overnoc. Pt. conts with weak, cogestive, productive cough. NT sx'ing not nec. thus far tonoc; pt. using oral sx. catheter to aide in clearing sputum. Pt. less \"gargly\" sounding overnoc. when compared to last noc. Lasix given on eves appears to have helped resp. status. Although, fine crackles appreciated bilat at bases. Pt. not tolerating lying in any position but bolt upright.\n\nCV- VSS. No issues. HR 50's-60's SR. BP maintained above 110. + pulses.\n\nDerm- Duoderm noted on coccyx, not removed to assess; documented ulcer. Cellulitic lower extremeties noted.\n\nGI- TF restarted this am at 10cc, ? why pt. was NPO...? impending intubation. ABd. soft, +BS. +BM. NGT in place.\n\nGU- F/C draining urine in adequate amounts, u/o dropping off this am to 30cc/ hr. No Maintence fluid ordered.\n\n Pt. conts on vanco, flagyl, ceftriaxone. Afebrile this shift.\n\nPlan- cont. to get OOB to chair, ? nec. for more lasix, ? d/c to the medical floor.\n\nCode status- addressed reintubation with pt. At this time, pt. stated she needs to discuss DNR status with her husband and together. There needs to be a formal meeting involving pt. before d/c to floor.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501890, "text": "NURSING TRANSFER NOTE\nMS C. IS A 77 YO FEMALE WITH RENAL CELL CA METASTATIC TO THE LUNGS. ON HAD COUGHING ATTACK WITH NAUSEA AND HAD BRB HEMOPTYSIS. PT ADMITTED TO FLOOR BUT HAD RESP DECOMPENSATION AND WAS SENT TO MICU EAST FOR INTUBATION. SHE WAS THEN TX ON TO THE WEST MICU AFTER HAVING STENTS PLACED IN TRACHEA. SHE WAS EXTUBATED BUT DECOMPENSATED ON 0200 AND WAS REINTUBATED .\nMS. C IS NOW GOING BACK TO TO HAVE RADIATION THERAPY AS PALLIATIVE TX.\n\nPMH--HYPOTHYROIISM,S/P NEPHRECTOMY.\n\nALLERGIES--SULFA, IV CONTRAST.\n\nROS--\nCARDIAC--EPISODES OF HYPOTENSION AND RECIEVED SEVERAL BOLUSES OF NS . DESPITE BEING ON 7 MCG KG MIN OF DOPA SHE REMAINS WITH MAP 60. HR 90-100 SR/ST WITHOUT ECTOPY . K+ REPLETED FOR K+3.3\n\nRESP--ON A/C 50%X550 5PEEP.10 IPS. SHE IS BREATHING OVER VENT. SX Q2 HR FOR THIN BLOOD TINGED SPUTUM. SAO2 97% BUT DESAT TO 80. AND PT RETURNED TO BASELINE WITH THIS. LUNGS COARSE. RLL DIMINISHED.\n\nGI--NO TUBE FEEDS ALTHOUGH PT HAS NGT. NO STOOL. NO TPN AT THIS TIME.\n\nGU--UO INCREASED TO ABNORMAL AMTS AND IS NOW PUTTING OUT 400-500 CC HR. TEAM AWARE. URINE LYTES AND OSMO SENT.\n\nENDO--UNREMARKABLE\n\nNEURO--PT ON PROPOFOL AT 20 MCG/KG MIN. SHE CAN FOLLOW SIMPLE COMMANDS, MAE SPONT AND TO COMMAND. PEARL AT 3MM.\n\nCOPING--FAMILY PRESENT. THEY ARE CONCERNED ABOUT ALL THE TRANSFERS BACK AND FORTH. ASKING QUESTIONS.\n\nA---HYPOTENSION PERSISTS DESPITE BEING ON DOPA.\n\nP--TX TO FOR RADIATION TX.\n\nLINES--R FEMORAL TRIPLE LUMEN, R RADIAL ART LINE\n\nDISP--FULL CODE AT PRESENT PER PT WISHES.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501891, "text": "Pt. admitted from MICU-West. Transferred per EMT. Pt. remains intubated on AC rate 10, Fio2 50% with O2 sat's >95%. Sedated on propofol gtt. Opens eyes to speach, follows commands appropriately. Denies pain/discomfort. ECG showing ST, Dopamine gtt maintained for B/P >60. Increased urine output, noted. MICU team aware. Urine lytes sent earlier, waiting for results. Husband and brother visited, updated. Went home for the day. Will call back later for an update.\nNo schedule for radiation treatment at this time... JLuxRN\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501892, "text": "Dpoamine titrated down to keep mean >60. Pt. remains sedated. No changes in assessment. Duoderm intact to sacral area. Cousins of patient in to visit and updated. No plans for radiation tx. today.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501893, "text": "PATIENT TRANSFERED FROM TO EAST. ON MECHANICAL VENTILATION AT A/C %-5P; PH 7.39. SUCTIONED BLOOD OUT OF ETT. SAT 1005 will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-21 00:00:00.000", "description": "Report", "row_id": 1501894, "text": "RESPIRATORY CARE NOTE\nReceived pt intubated on vent setting A/C tidal volume 550 Rate 10 FiO2 50% peep 5. Suctioned ETT for mod amt of blood/tan secretions. Breath sounds improve after suctioning. Will cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-21 00:00:00.000", "description": "Report", "row_id": 1501895, "text": "NSG PROGRESS NOTE\nsedated on propofol, able to follow commands, sleeps when left alone\n\nremains vented with good abg's, initially suctioned for very thick tan old bloody secretions, this am, scant tan sputum\n\ncontinues on dopamine, increased for hypotension. defervesed\n\nngt clamped, pos BS, minimal residual\n\nu/o qs\n\nturned side to side q2hrs\n\na- continues to require ventilatory support\n\np- cont pulm hygeine\nwean dopa as able\n" }, { "category": "Nursing/other", "chartdate": "2142-07-25 00:00:00.000", "description": "Report", "row_id": 1501908, "text": "UPDATE:NEURO/PSYCH:PT.EASILY AROUSED BUT SLEEPY-RESPONDING TO COMMAND,MAE.C/V:BP DROPPED AS LOW AS 70 SYSTOLIC-DR. NOTIFIED,PT.SLEEPING SOUNDLY-LOW DOSE DOPA STARTED @ 2MCG/KG/MIN FOR 2HRS-CURRENTLY OFF WITH SBP IN THE 120'S.MP-SB TO NSR WITH RARE PVC,SKIN WARM & DRY WITH PALP.PEDALS.RESP:PT.RESTED FAIRLY WELL ON CPAP WITH 10IPS WITH TV'S 250-400CC & RR LOW 20'S TO LOW 30'S,SX'D Q2HRS FOR MOD.THICK YELLOW SPUTUM,PT.SX'D ORALLY FOR LG AMTS OF CL.SECRETIONS.GU:HUO MARGINAL EARLIER WITH CONT.'D HIGH NA-MAINTENANCE IV INC'D TO 100CC/HR & FREE H2O BOLUES VIA NGT INC'D TO 300CC Q6HRS,HUO IMPROVED AFTER R-DOPA STARTED-NOW THAT DOPA IS OFF AGAIN WILL WATCH CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-25 00:00:00.000", "description": "Report", "row_id": 1501909, "text": "PT.ON 5 CPAP-10 IPS-40%+FB/VT.300-400 ON OWN, RR.23-29/ALERT AND ORIENTED./MDI ALBUTEROL GIVEN Q4H,BREATHE SOUNDS CLEAR BILAT.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-25 00:00:00.000", "description": "Report", "row_id": 1501910, "text": "PT EXTUBATED THIS AFTERNOON, CURRENTLY AWAKE AND ALERT, O2 3LNC POX 97-100%, VSS, BP 124/62- 155/70, HR SB 50'S PVC'S THIS AFTERNOON, LYTES DRAWN, RESULTS PENDING, NA 142 THIS AFTERNOON, UOP LOW 250CC NSS FLUID BOLUS INFUSING, FOLEY CATH DRAINING CLEAR YELLOW URINE, 25-60CC/HR, U/A SENT THIS AFTERNOON, H2O FLUSHES ON HOLD @ THIS TIME AS MD, TF ON HOLD, NGT REMAINS CLAMPED, ABD SOFT, INCONT LOOSE BROWN STOOLS, TRACE HEME +, PT TURNED , SUCTIONED THICK TAN SECRETIONS SM TO MOD AMTS, LUNGS COARSE WHEEZES, ALBUTEROL TX GIVEN, PT RESTING MORE COMFORTABLE AT THIS TIME, SEE FLOWSHEET FOR FULL ASSESSMENTS\n" }, { "category": "Nursing/other", "chartdate": "2142-07-26 00:00:00.000", "description": "Report", "row_id": 1501911, "text": "micu npn 7p-7a\n\nrespiratory-> pt remains extubated but is having difficulty clearing secretions. she was suctioned x2 for large amts of thick, tan sputum. lung sounds remains course despite suctioning. abg this morning: 163/41/7.36/24/-1.\n\ncardiac-> pt was again hypotensive to sbp ~75 several hours after receiving ivp lasix for ?volume overload on cxr. she was given a 250cc ns fluid bolus w/good effect. currently, sbp 90-110 range w/hr 50-60's, sb-sr w/frequent pvc's. lytes were w/in normal limits but repeat chemistries pnding this morning. total fb is slightly positive after receiving the fluid bolus earlier this am.\n\nneuro-> pt is a&ox2 and has been cooperative w/care. she has had many somatic complaints overnoc. she received tylenol x1 for c/o a ha.\n\ngi-> abd soft, nontender w/+bs. pt had a loose bm x1 overnoc. she remains npo for now given tenuous respiratory status.\n\ngu-> uo excellent following lasix dosing although currently only ~40cc/hr. tfb slightly positive at the present time. ?pt's fluid status overall and wonder if it may be appropriate to place a pa catheter to help direct care.\n\nendo-> fs range 120's overnoc; pt did not receive insulin per sliding scale coverage.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-26 00:00:00.000", "description": "Report", "row_id": 1501912, "text": "addendum to npn 7p-7a\n\nrepeat k+ 3.1 this morning. pt is currently receiving 20meq iv kcl and is ordered for a second. please check a repeat k+ level at 11am.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-26 00:00:00.000", "description": "Report", "row_id": 1501913, "text": "Respiratory Care note\n Pt seen this A.M. and /tracheal sx for small amnt of thick blood tinged secretions. Deep breath and cough done with patient. Pt with NPC. Currently sitting up oob in NARD sats 96-99% Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 1501886, "text": "MICU NPN 7PM-11PM:\nPt's resp status very poor with increasing congestion and aspiration. After discussion with ICU team the decision was made by her that she wanted to be intubated in order to live. Even if it means living the rest of her life on the vent. The plan is to intubate her and insert central line and A-line and for her to be transferred to MICU on the with the plan for her to get emergent XRT tomorrow.\n\nPt intubated. Has dropped her BP and given fluid boluses 250cc's times three. Now on the vent on 550/10/50% FIO2 with 5cm peep on AC. Suctioned for lrg amt thick blood tinged secretions. Pt started on a propofol drip for sedation and is on 12mcg/kg/min at this point. UO has dropped this eve since her BP has been low. A-line has been inserted and next will plan for a-line. Plan also for transfer East tonight if stable.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501887, "text": "Resp Care Note:\n\nPt electively intub for airway protection. ETT placed without incident and placed on mech vent as per Carevue. Lungs rhonchi. Sx mod to large amt rusty sput. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501888, "text": "MICU NPN 11pm-7am\nNeuro: PT. on propofol at 12mcg, obeying commands, denies pain, pt. given small boluses as BP tolerates for comfort while inserting central line. Bilateral soft restraints on to protect integrity of ett.\n\nResp: Received on tv550, +5 100%, Ac10. ABG post intubation with acceptable po2 and attempted to decrease fio2 to 30%, however after receiving fluids sat decreased to the low 90's and pt. placed back on 100%. AM abg pending and will titrate fo02 accordingly. Suctioned for thick, copious amounts of rusty colored sputum, culture sent. Lungs are extremely coarse with scattered rhonci throughout.\n\nCV: SBP and MAP decreasing prior to intubation and pt. given multiple fluid boluses without any increase in BP. Post intubation BP remained low and still did not respond to fluid boluses. Started on dopamine at 4mcg/kg/min and maintained there while several attempts were made at a central line placement. Pt. currently being maintained on dopamine for Bp support. NSR no ectopy noted.\n\nGI: Currently npo, has ngt in. Active bowel sounds, pt. will need to have nutrition addressed today.\n\nGU: foley initially with very decreased urine output, however after several fluid boluses, urine output has markedly picked up.\n\nACCESS: PT. without central line and needing access for dopamine. R femerol line placed this am. Peripheral line on L hand d/c'd due to infiltration. R radial aline also placed.\n\nPT. is a full code, after speaking with Dr. . Plan initially prior to deteriortation was to transfer pt. to MICU for radiation therapy is on east.\nSee careview for further details.\nSKIN: Bloody, blistered area on lips noted ? hepres. Dr. and aware, possible Derm consult today to determine.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-20 00:00:00.000", "description": "Report", "row_id": 1501889, "text": "MICU Nursing Addendum\nPT. noted to start having alot of urine output. ANd now having frequent pvc's and pac's. Dr. aware. Am labs are pending, but additional stat k and ionized ca sent.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1501880, "text": "PMICU NSG PROGRESS NOTE\nRESP: REMAINS INTUB/VENTED ON SIMV 550X10 40% 5PEEP 5PS WITH STABLE 02 SATS. SUCTIONED FOR SM AMTS OLD BLOOD ONE SMALL CLOT. PT MORE AWAKE. WILL TRY PS WEAN IN AM.\nCARDIAC- CONT WITH LOW BP 88-95/40-60. PT GIVEN 2ND 500CC NS BOLUS WITHOUT MUCH CHANGE IN BP. UO CONT BOARDERLINE 20CC/HR.\nGI- WITHOUT C/O. REMAINS NPO. PT GIVEN SM AMTS ICE CHIPS.\n PT AWAKE ALERT AND COOPERATIVE. C/O DISCOMFORT WITH ET TUBE. GIVEN 1MG ATIVAN WITH IMPROVEMENT. SLEEPING ON AND OFF.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-23 00:00:00.000", "description": "Report", "row_id": 1501902, "text": "PMICU NURSING NOTE\nNEURO: MUCH MORE QUIET THIS EVE. AROUSEABLE TO ACTIVITY. PROPOLOL DOWN SLIGHTLY W/O MUCH CHANGE. PUPILS 2MM/EQUAL/RX. MAE.\nEYES-CRUSTY-REQUIRE RINSING TO OPEN. LACRILUBE ORDERED. NO REDNESS SEEN\nSKIN-DRY LEGS AND FEET FLAKY\nIVF 150 NS OVERNIGHT. RECEIVING FLUID BOLUSES. URINE IS NOW LIGHT YELLOW.\nRESP SATS 100%. NO CHANGES ON VENT. ONE ABG -ARTERIAL LINE HARD TO DRAW FROM AND SOMETX DAMPENED. NBP ON STANDBY IF NEED BE. SUX FOR THICK TAN SECRETIONS.LG SECRETION SUX BACK OF MOUTH TURNED S-S NOT TOL SIDES WELL. LUNGS SOUND EXT COARSE. CPT X2 TX BY RT\nVSS DOPA AT 4.4 MCGS\nA: AS ABOVE.\nP: CHECK W/TEAM RE IVF FOR NEXT LITER\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-23 00:00:00.000", "description": "Report", "row_id": 1501903, "text": "Patient remains on same settings (SIMV). Alert ,coop , responding to commands. On MRSA precaution, BS rhonchious, some wheezes. Suctioned minimal amount of secretion via ETT, treated with albuterol, will continue to follow\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-23 00:00:00.000", "description": "Report", "row_id": 1501904, "text": "RESP; LUNGS COARSE THROUGHOUT THE DAY. SUCTIONED FOR SMALL AMTS OF THIN WHITE SECRETIONS. LAVAGED AND . X2. NO VENT CHANGES TODAY.\nRENAL: CONTINUES TO AUTODIURESE. IN NEG BALANCE AT PRESENT. AWAITING ACTH RESULTS.\nGI; TOL TF'INGS WELL. NO BM YET. NEED TO GIVEN LACTULOSE TONIGHT. BS'S HYPOACTIVE. FREE WATER BOLUSES GIVEN. NO BM RECORDED SINCE ADMISSION.\nCV: ATTEMTP AT WEANING DOPAMINE UNSUCCESSFUL. BP DIPPED TO 60'S, BY A-LINE, BUT CUFF PRESSURE WAS 78. GIVEN 100CC NS BOLUS AND DOPAMINE UPPED TO PRESENT RATE. NO FURTHER ATTEMPT. A-LINE IS VERY POSITIONAL AND DOESN'T DRAW.\nSEDATION: WHEN PROPOFOL INFUSED, CAN CHANGE TO ATIVAN AND MS DRIP. PT. WILL NOT BE WEANED YET.\nNEURO: PT. SEDATED, BUT DOES AWAKE AND ANSWER QUESTIONS APPROPRIATELY.\nENDOC: MG+ AND K+ REPLACED. LAST K+ 3.8. YOU DO HAVE A PRN ORDER FOR K+ < 4,0.\nID: AFEBRILE. CONTINUES ON HER ANTIBIOTICS. PT. IS + MRSA IN SPUTUM.\nSOCIAL: FAMILY INTO SEE PT.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-24 00:00:00.000", "description": "Report", "row_id": 1501905, "text": "PMICU NURSING NOTE\nCV: REMAINS DOPA DEPENDENT ON 2-4MCG. PVC'S-K+ PND. URINE OUT AT LEAST 100/HR.\nSEDATION: PROPOFOL D/C'D AND ATIVAN GTT STARTED. PT IS QUITE SEDATED BUT AREOUSABLE ON 1MG/HR. MSO4 GTT HELD B/C OF SEDATION, BUT IS ON STANDBY IN CASE NEED FOR PAIN/ADDITIONAL SEDATION CONTROL\nGI: HAD NO STOOL SINCE ADMIT TO MICU-AND HAS BEEN TOLERATING TF-THEREFORE GAVE COLACE/LACTULOSE AND DULCOLAX SUPP FOR HUGE RESULTS, BROWN LIX TR +\nRESP: CONT W/VERY COARSE LUNGS SOUNDS AND SPUTUM IS TAN, THICK-LG AMNT FROM BACK OF THROAT.\nNO CHANGE IN VENT SETTINGS\nLABS: PND. REPLETE AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-24 00:00:00.000", "description": "Report", "row_id": 1501906, "text": "Respiratory Therapy\nPt changed to PSV in hopes of extubation. ABG on PSV WNL however, pt not very arousable to voice. Minimal secretions. Receiving Albuterol MDI as needed. Plan to continue with PSV and try to extubate in AM.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-24 00:00:00.000", "description": "Report", "row_id": 1501907, "text": "PT REMAINS INTUBATED, CURRENT VENT SETTINGS CPAP PS10, 40% O2, POX 97-100%, SBP 91/37-142/55, HR 50-60'S, SR WITH FREQ PVC'S, K+ 3.2 THIS AM, 40MEQ K+ IV GIVEN, KPHOS GIVEN, ATIVAN AND DOPAMINE GTT D/C'D, SUCTIONED SM AMTS THICK TAN SECRETIONS, PT TURNED AND REPOSITIONED FREQ, INCONT LOOSE STOOL, NGT IN PLACE H2O FLUSHES GIVEN AS ORDERED, NA 152 THIS AM, FOLEY CATH IN PLACE DRAINING CLEAR YELLOW URINE, R RAD ALINE REMAINS IN PLACE, SEE FLOWSHEET FOR FULL ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1501881, "text": "RESP NOTE\nVent settings and outcomes in care view charting. Weaned Pressure support and oxygen down today. off SIMV to CPAP/PS. ABG results also in Care View charting.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1501882, "text": "ALTERED RESP STATUS\nD: THIS AM PT ALERT AND ORIENTED. INITIALLY WHEN IPS WAS TURNED DOWN ON VENT TVS WERE ONLY 100 SO IPS WAS SLOWLY WEANED OVER HRS. VENT SETTINGS OF 30% WITH 5 OF PEEP AND IPS OF 5 AND PT APPEARED COMFORTABLE AND ABG=7.37/40/114/24/-1. PT EXTUBATED AT 1530 AND NOW ON 40& OPEN FACETENT MASK WITH O2 SATS=>98%. C&R THICK OLD BLOOD TINGED SPUTUM. LUNG SOUNDS COARSE BIL WITH DECREASED BS TO THE BASES.HR HAS BEEN 70-80'S WITH OCCASIONAL PAC'S AND SBP 91-124. MAX TEMP=99.3.UO REMAINS MARGINAL AND WAS GIVEN 500CC NS BOLUS WITH POS EFFECT. WILL NEED TO CONTINUE TO FOLLOW I&O AND SHE NEED ADDTIONAL BOLUSES OF IVF.AT PRESENT SHE JHAS D5 1/2 NS AT 100CC'S/HR AND I&O IS POS BY 2L.HCT STABLE. THIS AM 36.6 AND REPEAT THIS AFTERNOON=34.7. CONTINUE WITH PRESENT MEDICAL TX AND FOLLOW I&O'S CAREFULLY. IF RESP STATUS DECOMPENSATES OR IF PT DEVELOPS HEMOPTYSIS. REMAINS A FULL CODE. HUSBAND IN TO VISIT THIS AM AND WAS UPDATED.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 1501883, "text": "Nursing Progress Note\nNeuro: A&Ox3. Assisting with turning in bed. Slept in naps overnight\nResp: BS coarse, diminished at bases bilat. Sats 92-95% on 35% cool neb open mask Coughing and raising thick pink tinged sputum\nCV: SR, noted to be in and out of vent bigeminy earlier in shift. K+ 3.7, given 40mEq KCl via NG tube with decrease in ectopy to rare unifocal PVC's. BP stable Tmax 99.5 PO IVF NS @ 100ml/hr\nGI: NPO except for ice chips +BS, no stool overnight\nGU: Urine output has picked up overnight to >60ml/hr\nSkin: Black crusted lesion on lips Lt>Rt ? HSV\nSocial: No contact with family overnight.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 1501884, "text": "MICU PROGRESS NOTE\n\nCV: SR OCC PVC NOTED.\n\nRESP: RESP STATUS DETERIORATING THROUGHOUT DAY. CXR DONE, NO CHANGE FROM PREVIOUS ONE. INITIALLY COUGHING AND RAISING THICK TAN SPUTUM, NOW NEEDS SUCTIONING. ABG'S POOR ON 35%, FIO2 INCREASED TO 70% WITH BETTER SATS.\n\nGU: UOP REMAINS HIGH.\n\nGI: BOWEL SOUNDS PRESENT. NGT CLAMPED.\n\nID: SPIKED TEMP 102.5, PAN CULTURED. PT TREATED WITH TYLENOL AND TO BE STARTED ON ANTIBIOTICS.\n\nSOCIAL: HUSBAND CALLED, NO VISITORS TODAY.\n\nNEURO: CALM, WEAK. FOLLOWS COMMANDS.\n\nASSESSMENT: RESP STATUS DETERIORATING, QUESTION ASPIRATION\n\nPLAN: START ANTIBIOTICS\nMONITOR TEMP\nGOOD PULM TOILET\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 1501885, "text": "RESPIRATORY CARE: PT. APPEARS A BIT MORE TACHYPNEIC\nWITH AUDIBLE CONGESTION. SPO2 92-94% ON .35 MASK.\nBS REVEAL RHONCHI. GIVEN 2.5 MG VENTOLIN VIA SVN\nFOLLOWED BY NT SUCTION FOR THICK TAN SPUTUM.\nGOOD SUB/OBJ IMPROVEMENT. WILL FOLLOW FOR Q4 PRN.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2142-07-27 00:00:00.000", "description": "Report", "row_id": 1501916, "text": "Physical Therapy/RSD\nS: \"I feel so weak after being in bed all this time\"\nO: Pt seen to address goals set at initial evaluation on \nLabs: 4.0>20.5<18\nVital Signs: 61, 143/57, 98% on 2LO2 (stable with rx)\nRx: Strengthening/ROM exercise in supine and sitting for bilateral upper and lower extremities. Pt transfered bed to chair by taking 5 steps with moderate assist of one person.\nCommunication: With nurse and patient regarding rehab process, pt's ability.\nA: Pt motivated to participate in physical therapy. Pt will benefit from d/c to rehab to maximize functional ability prior to return home.\nP: F/U \nPager: # \nTime Frame: 11:30-12:15am\n" }, { "category": "Nursing/other", "chartdate": "2142-07-27 00:00:00.000", "description": "Report", "row_id": 1501917, "text": "P-MICU NPN\n\nStable day. Remains congested but it has improved. O2sats 98% on 2l n/c. Appears more alert and stronger today. OOB-chair. Tol very well. Afebrile. R fem line dc'd. No visitors today. Husband called. to transfer to 5S this afternoon. Tol sips of water. TFs increased to 25cc/hr. Goal 50cc. Cont until PO intake improves.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-27 00:00:00.000", "description": "Report", "row_id": 1501918, "text": "addendum: repeat Hct pnd. Clot to blood bank and sma7 also sent.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 1501875, "text": "NURSING ACCEPTANCE NOTE\nPT IS A 77 YO FEMALE WITH METASTATIC LUNG DISEASE. SHE WAS TX TO MICU AFTER HAVING HEMOPTYSIS AND DECREASE IN BREATH SOUNDS. SHE WAS ADMITTED TO MICU AT 0900. ALS AMBULANCE HAS BEEN PHONED AND PT IS BEING TX TO MICU WEST THEN TO OR FOR STENT PLACEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 1501876, "text": "ADDENDUM\nPT ARRIVED WITH SBP126/60. HR A- FIB WITHOUT ECTOPY. GIVEN TOTAL OF 5 MG IV MIDAZOLAM , AND 25 MG IV PROPOFOL FOR SEDATION FOR EXTUBATION. SHE IS NOW ON A PROPOFOL GTT AT 10 MCG/KG/MIN. HER SBP DECREASED TO 75/40 FOR ~20 MIN VUT HAS NOW RESOLVED WITH SBP 100/50.\nMS C. SHOULD BE GETTING NS FOR IVF BU ONLY HAS A 22 AT PRESENT. WILL ATTEMPT TO START ANOTHR PERIPHRAL.\n\nRESP--INTUBATED WITH 7.5 TUBE. THICK BLOODY SPUTUM. DECREASED BREATH SOUNDS IN ALL FIELDS. SAO2 92-97%.\n\nGI--NGT PLACED. CXR DONE. BILIOUS BLOOD TINGED SECRETION. HYPOACTIVE BOWEL SOUNDS.\n\nGU--FOLEY CATH PLACED. SHOULD SEND SPECIMEN AS URINE IS CLOUDY WITH SEDIMENT.\n\nNEURO--PRIOR TO INTUBATION, PT WAS ALERT AND ORIENTED X3. MOVED EXTREMITIES SPONT AND TO COMMAND.\n\nENDO--UNREMARKABLE AT PRESENT.\n\nAWAITING AMUBLANCE FOR TX TO .\n" }, { "category": "Nursing/other", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 1501877, "text": "Transfer to MICU RN Note.\n is a 77 year old woman admitted to BIDH on c hemoptysis s prodrome. Pt PMH notable for Met Renal CA c Lung mets originally Dx . Initially the pt was treated at BIDH on a gen med floor, however this am the pt became progressively SOB c frank bloody hemoptysis and hypoxemia (decreased SaO2). The pt was emergently intubated on the floor and brought to BIDH MICU for more aggressive care. The pt was held here for approximately 60 minutes before being taken to the OR for bronchoscopy and bilateral stent placement. On return to the MICU pt notably sedated from procedure and HD stable. Of note, pt c improved BS on r side which prior to procedure had been greatly diminished. Per the team, the goal to is wake up the pt and attempt to extubate rapidly. No family members have been present during here time in the MICU thus far, though family members were notified and consent was obtained for her procedure.\nPULM: coarse BS b/l, c slightly decreased bs on r side. nl sat, breathing c vent. AC settings of 14-100%-550-5.0 peep c PAP's in high 20's. Thick bloody sec prior to OR, not Sx since return, no cough at this time. CXR obtained prior to transfer to MICU.\nCV: Pt c an episode of hypotension prior to OR which responded rapidly to profolol gtt d/c and fluid bolus (1000 ml). NSR c PAC's, EKG obtained at BS at 1200.\nINTEGUMENTARY: skin intact on back. notable skin sloughing and scaley skin of LE's. Thin skin, poor venous access noted. Restraints in place to protect ETT.\nGU: Foley placed just prior to transfer to MICU c notably pale, cloudy/purulent urine evident. Both a urinalysis spec and spec for C&S were sent. Per team, the pt is probably hypovolemic.\nNEURO: The pt has been sedated while here on the MICU service, however prior to going to the OR she was following commands and opening eyes to voice. Pt is restrained to protect ett. Propofol gtt infusing at 10 mcg/kg/min via r piv placed earlier today. Per team will attempt to wean propofol down to promote ventilator weaning. The pt is a full code.\nGI:Pt has an OGT in place, CXR performed but still awaiting word as to whether the cath is in correct position. Abd slightly distended (sl obese), abd is soft. NPO.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 1501878, "text": "Micu Nursing Progress Note\nResp: Pt on PSV of 15 with TV 500, but her tidal volumes started to drop around to 200-300 and she started having episodes of apnea around 2200 so she was placed on IMV 550 x10 PSV 5/Peep5 for the night. She was suctioned X1 for small amount of bloody secretions.\n\ncardiac: B/P 100-110/40 HR 70's. With the above change her B/P came down to 89/26. Her U/O was an average of 40cc for 4 hours so at 2200 she was bolused with 500cc NS.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1501879, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 550, Simv 10, Fio2 40%, Peep 5, with Psv 5. PAP/Plateau 25/20. Pt. changed to Simv/Psv from Psv due to periods of apnea. RR decreasing to 5. Bs coarse bilaterally. O2 sats 100% on above setttings. No further changes made. Continue with mechanical support and wean to Psv as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-26 00:00:00.000", "description": "Report", "row_id": 1501914, "text": "P-MICU NPN 0700-1900\nREMAINS EXTUBATED W/O2 SATS 98-100%. CONTINUES TO HAVE ALOT OF UPPER AIRWAY CONGESTION. WEAK COUGH. UNABLE TO CLEAR MOST OF HER SECRETIONS BUT ?SWALLOWS SOME. THEY ARE TOO DEEP FOR BACK OF THROAT SUCTIONING BUT OCC CAN GET DOWN FAR ENOUGH TO CLEAR MOD AMTS. WEAK TO ABSENT GAG. SOUNDS CONGESTED EVEN AFTER NT SUCTIONING. STATED THIS AM SHE DOESN'T WANT THE BREATHING TUBE AGAIN. DR. TPO SPEAK WITH PT REGARDING CODE STATUS. OOB-CHAIR X 2HRS. TOL WELL. LIKES TO BE SITTING BOLT UPRIGHT WHEN SHE IS IN BED. ART LINE DC'D BUT FEM LINE REMAINS IN AS PERIPHERAL ACCESS IS POOR AND SHE IS STILL ON VANCO. PASSING MOD AMTS OF LIQ BROWN STOOL. COLACE HELD. NO VISITORS TODAY. HUSBAND .\n" }, { "category": "Nursing/other", "chartdate": "2142-07-21 00:00:00.000", "description": "Report", "row_id": 1501896, "text": "Respiratory Therapy\nPt weaned to SIMV/PS and 0.40 this morning. ABG on curent settings WNL. LS coarse, suctioning thick yellow-BT secretions. Sedated with Propofol. Plan to continue with current settings and wean as tolerated.\n" } ]

[ { "category": "Physician ", "chartdate": "2192-06-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 473321, "text": "Chief Complaint: bleeding/intubated\n HPI:\n Pt is a 70 y.o male with h.o stage 4 metastatic lung ca who presented\n to the ED originally with bleeding from his back secondary to\n metastasis. While in the , pt developed \"Vtach\" and had to be shocked\n 3 times. After, being shocked, pt developed \"bradycardia\" and had to be\n intubated and given atropine. Given hypotension, pt was started on\n pressors, maxed on neosynephrine and dopamine. After these events,\n family decided to make pt upon arrival to the ICU.\n .\n Currently, pt is intubated and sedated.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions: morphine gtt\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Stage 4 metastatic NSCLC, undergoing chemo.\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Flowsheet Data as of 03:39 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 114 (114 - 114) bpm\n BP: 98/59(69) {98/59(69) - 98/59(69)} mmHg\n RR: 20 (20 - 20) insp/min\n SpO2: 100%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n RR (Spontaneous): 6\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 14 cmH2O\n SpO2: 100%\n Ve: 11.8 L/min\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal, No(t) Absent), (S2:\n Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Diminished: on the Left.)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: mottled extremities\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Pt is a 70 y.o male with h.o MI, stage 4 metastatic lung ca that\n presented with bleeding, now s/p VT and on pressors.\n .\n #goals of care- given the above situation and the extent of pt's\n illness, pt's HCP and family decided to the make the pt . Pt's\n family hopes for a peaceful death. Pt's family wishes to withdraw the\n pressor medications as well as extubate the pt in hopes that he is\n comfortable.\n .\n Case d/w attending.\n ICU Care\n Nutrition: n/a\n Glycemic Control: n/a\n Lines: R.femoral line\n Prophylaxis:\n DVT: n/a\n Stress ulcer: n/a\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: ICU\n" }, { "category": "General", "chartdate": "2192-06-09 00:00:00.000", "description": "ICU Event Note", "row_id": 473322, "text": "Clinician: Resident\n Met with pt's family, including daughters, HCP, and pt's wife who\n confirmed that pt is . They would like pressors to be stopped and pt\n to be extubated.\n Patient is critically ill.\n" }, { "category": "General", "chartdate": "2192-06-09 00:00:00.000", "description": "ICU Event Note", "row_id": 473378, "text": "Clinician: Resident\n Met with pt's family, including daughters, HCP, and pt's wife who\n confirmed that pt is . They would like pressors to be stopped and pt\n to be extubated.\n Patient is critically ill.\n ------ Protected Section ------\n Spoke with attending Dr. regarding plan and confirmed\n pt\ns status.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:22 ------\n" }, { "category": "General", "chartdate": "2192-06-09 00:00:00.000", "description": "ICU Event Note", "row_id": 473362, "text": "Clinician: Attending\n 70 yo man with h/o metastatic sqmous cell lung ca with persistently\n bleeding metastasis to spine. Pt came to ED today with ongoing\n bleeding from open back wound. Cardiac arrest in ER with extended\n resusitative efforts. Pt intubated. Family decided to switch goals of\n care to comfort. Pt transferred to MICU. Pt agitated and\n uncomfortable at times in MICU. Met with family who maintained that\n would like to switch goals to comfort and discontinue pressors and\n mechanical ventilation. Will work on pain/dyspnea control prior to\n discontinuing mechanical ventilation.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "General", "chartdate": "2192-06-09 00:00:00.000", "description": "ICU Event Note", "row_id": 473400, "text": "Clinician: Resident\n Pt with stage 4 metastatic lung ca. Pt made CMO earlier today. At about\n 920, pt developed Vtach which then progressed into bradycardia and then\n asystole. Pt's family at the bedside when he expired.\n exam:\n pt not arousable. No breath, heart sounds or pulse.\n" }, { "category": "Nursing", "chartdate": "2192-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 473401, "text": "Patient received CMO on morphine gtt. Family at bedside when patient\n passed away at approximately 21:20.\n" }, { "category": "ECG", "chartdate": "2192-06-09 00:00:00.000", "description": "Report", "row_id": 233703, "text": "Atrial fibrillation with a bradycardic ventricular rate of 56 beats per minute.\nAn RSR' morphology in lead V3 suggests transposition in leads V2 and V3. Right\nbundle-branch block with transposition in leads V2-V3. Compared to tracing #5\nthere are no diagnostic changes. There is again evidence of acute inferior\ninjury on top of a pre-existing inferior Q wave infarction with improvement in\nthe anterolateral ischemia.\nTRACING #6\n\n" }, { "category": "ECG", "chartdate": "2192-06-09 00:00:00.000", "description": "Report", "row_id": 233704, "text": "Atrial fibrillation with a bradycardic ventricular rate of 57 beats per minute.\nAn RSR' morhology in lead V3 suggests transposition of leads V2 and V3. Right\nbundle-branch block persists. Compared to tracing #4 the rate has slowed\nsignificantly. Inferior Q waves persist with suggestion of inferior ST segment\nelevation. The ST segment depressions in the lateral leads are improved in\nleads I, aVL and V2-V3 but persist in lead V4. Tracing continues to raise\nconsideration of inferior injury and improved lateral ischemia.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2192-06-09 00:00:00.000", "description": "Report", "row_id": 233705, "text": "Sinus tachycardia with right bundle-branch block. An RSR' morpology in lead V3\nsuggests transposition of leads V2 and V3. Compared to tracing #1 evidence of\nanterior ischemia in the setting of prior inferior myocardial infarction and\nright bundle-branch block persists. Q waves are now apparent in leads V4-V6 in\nthe setting of anterior R wave progression, again suggestive of prior lateral\nmyocardial infarction.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-06-09 00:00:00.000", "description": "Report", "row_id": 233923, "text": "Baseline artifact. An RSR' morphology in lead V3 suggests transpotion of\nleads V2 and V3. The rhythm is now irregular, most consistent with atrial\nfibrillation with a poorly controlled ventricular rate of 165 beats per minute.\nInferior ST segment elevations in leads III and aVF are now apparent suggestive\nof acute inferior injury. ST segment depressions persist in leads I, aVL, V4\nbut are somewhat improved in leads V2-V3 with ongoing right bundle-branch\nblock. Tracing raises consideration of inferior myocardial infarction with\nlateral ischemia.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2192-06-09 00:00:00.000", "description": "Report", "row_id": 233924, "text": "Sinus tachycardia. An RSR' morphology in lead V3 suggests transposition of\nleads V2 and V3. Compared to tracing #2 there are no diagnostic changes.\nEvidence of right bundle-branch block with prior inferior and lateral\nmyocardial infarction and anterior ischemia persists, although the ST segment\ndepressions in leads V2-V3 are less downsloping and more horizontal. Two\nmillimeters of slightly downsloping ST segment depressions are now apparent\nin leads I and aVL and more prominent in leads V4, also consistent with\nongoing lateral ischemia.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2192-06-09 00:00:00.000", "description": "Report", "row_id": 233925, "text": "Sinus tachycardia. An RSR' morphology in lead V3 suggests transposition of\nleads V2 and V3. Right bundle-branch block with two millimeters downsloping\ndepression in leads V2-V4 suggestive of ischemia. Prior inferior Q wave\nmyocardial infarction. There is anterior R wave regression consistent with\nprior lateral myocardial infarction. Also, one millimeter ST segment\ndepression downsloping in lead V5 and horizontal ST segment depression of one\nmillimeter or less in leads I and aVL, as well as in lead II. Tracing is\nsuggestive of anterolateral ischemia. Compared to the previous tracing\nof the rate is much faster. Downsloping ST segment depression in\nleads V2-V4 is much more pronounced. Evidence of inferior myocardial\ninfarction and right bundle-branch block persist.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2192-06-04 00:00:00.000", "description": "Report", "row_id": 233926, "text": "Sinus rhythm at upper limits of normal rate. Since the previous tracing\nno significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-06-04 00:00:00.000", "description": "Report", "row_id": 233927, "text": "Sinus rhythm. Short P-R interval. Consider inferior myocardial infarction.\nRight bundle-branch block. ST-T wave abnormalities. Since the previous\ntracing of probably no significant change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2192-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1090287, "text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with bleeding\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 70-year-old male with bleeding.\n\n COMPARISON: Chest radiograph one week ago.\n\n SINGLE PORTABLE SEMIUPRIGHT VIEW OF THE CHEST: The study is essentially\n unchanged from one week ago, with a combination of left lung base tumor, post-\n obstructive consolidation and pleural effusion again noted. 6-mm left upper\n lobe nodule is redemonstrated. There is an unchanged small right pleural\n effusion. The right lung is otherwise clear. Osseous structures and soft\n tissues appear unremarkable.\n\n IMPRESSION: No significant change in tumor, postobstructive consolidation and\n effusion at the left lung base.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2192-06-09 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1090312, "text": " 2:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: tube placement\n Admitting Diagnosis: BACK WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new intubation and compressions\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW, \n\n HISTORY: New intubation. Check tube.\n\n REFERENCE EXAM: at 10:20.\n\n FINDINGS: There is a new ET tube with tip 3.2 cm above the carina. The NG\n tube tip is in the proximal stomach. There continues to be a moderate left\n pleural effusion that is slightly increased in size compared to earlier the\n same day with dense retrocardiac opacity consistent with known tumor\n with associated volume loss/infiltrate and effusion. There is a small right\n effusion as well.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2122-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981161, "text": " 1:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for acute process.\n Admitting Diagnosis: CHEST PAIN;TELEMETRY,HYPOPHOSPHATEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with anemia, hypoglycemia, and hypophosphatemia, known R\n pleural effusion of unclear etiology desatting.\n REASON FOR THIS EXAMINATION:\n Please eval for acute process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anemia with right pleural effusion.\n\n FINDINGS: In comparison with the study of , there is continued and\n possibly slightly increased opacification at the right base consistent with\n pleural effusion. The status of the underlying lung is difficult to evaluate\n and the possibility of atelectasis or pneumonia can certainly not be excluded.\n The central catheter tip again extends to the lower superior vena cava just\n above the junction with superior vena with the right atrium.\n\n IMPRESSION: Little overall change.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2122-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980633, "text": " 12:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: CHEST PAIN;TELEMETRY,HYPOPHOSPHATEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with anemia, hypoglycemia, and hypophosphatemia\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anemia.\n\n Single portable radiograph of the chest again demonstrates a moderate\n right-sided pleural effusion, unchanged from . Right basilar\n atelectasis persists. Right internal jugular central venous catheter is\n unchanged with its tip in the right atrium. Trachea is midline. Left lung is\n clear. No pneumothorax.\n\n IMPRESSION:\n\n Persistent right basilar atelectasis and right-sided pleural effusion.\n Pneumonia is not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-09-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980949, "text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? assess for change in R pleural effusion from prior\n Admitting Diagnosis: CHEST PAIN;TELEMETRY,HYPOPHOSPHATEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with anemia, hypoglycemia, and hypophosphatemia, O2 sat\n 100% on RA, known R pleural effusion of unclear etiology.\n REASON FOR THIS EXAMINATION:\n ? assess for change in R pleural effusion from prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anemia with right pleural effusion; assess for change.\n\n FINDINGS: In comparison with study of , there is little change in the\n right pleural effusion. The remainder of the examination is also unchanged.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2122-09-27 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 980782, "text": " 7:43 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: R/O DVT SWELLING\n Admitting Diagnosis: CHEST PAIN;TELEMETRY,HYPOPHOSPHATEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD on HD and SLE with new on set L arm swelling and\n pitting edema\n REASON FOR THIS EXAMINATION:\n please eval for evidence of dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease on hemodialysis with new left arm\n swelling.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler imaging of the internal jugular,\n subclavian, axillary, brachial, basilic, and cephalic veins were performed.\n There is evidence of extensive thrombus extending from the subclavian vein\n through the basiliac vein. Evaluation of the left internal jugular vein is\n limited, though it may also contain thrombus. The cephalic vein appears\n patent. Brachial vein evaluation is limited, though at least one appears\n patent.\n\n IMPRESSION:\n\n 1. Left upper extremity deep venous thrombosis extending from the internal\n jugular vein through the basilic veins.\n\n Findings discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2122-09-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 980985, "text": " 12:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: tachypnea, acute intracranial process?\n Admitting Diagnosis: CHEST PAIN;TELEMETRY,HYPOPHOSPHATEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ESRD, hypophophatemia, primary respiratory alkalosis\n REASON FOR THIS EXAMINATION:\n tachypnea, acute intracranial process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: CT head.\n\n HISTORY: 66-year-old female with end-stage renal disease, respiratory\n alkalosis with tachypnea. Evaluate for intracranial acute process.\n\n TECHNIQUE: MDCT axial acquired images through the skull were obtained from\n the base to the vertex. No IV contrast was administered.\n\n FINDINGS: There is no evidence of acute hemorrhage or mass. There is no\n shift of normally midline structures. The ventricles and sulci are prominent,\n consistent with age-appropriate involutional changes. There is normal -\n white matter differentiation. There are periventricular hypodensities,\n consistent with chronic microocclusive small vessel disease. A small area of\n subinsular hypodensity is unchanged in appearance since previous exam and\n likely represents an old lacunar infarct. The visualized paranasal sinuses are\n unremarkable. There are degenerative changes of the bilateral\n temporomandibular joints noted.\n\n IMPRESSION:\n\n 1. No evidence of acute intracranial process. Chronic small vessel\n microocclusive disease as described above.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2122-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980407, "text": " 12:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for ptx\n Admitting Diagnosis: CHEST PAIN;TELEMETRY,HYPOPHOSPHATEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with anemia, hypoglycemia, and hypophosphatemia -> s/p\n attempted line placement\n REASON FOR THIS EXAMINATION:\n please assess for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post attempted line placement. Evaluate for pneumothorax.\n\n COMPARISON: AP and lateral chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: There is no pneumothorax on this film. A\n right subclavian hemodialysis catheter terminates in the right atrium. Right\n middle and right lower lobe atelectasis is unchanged, with hyperexpansion of\n the right upper lobe. An underlying pneumonia or effusion is not excluded.\n The left lung is clear. The surrounding soft tissue and osseous structures\n are unchanged.\n\n IMPRESSION:\n 1. No pneumothorax.\n 2. Persistent right middle and right lower lobe atelectasis. Underlying\n pneumonia or effusion are not excluded.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-09-27 00:00:00.000", "description": "Report", "row_id": 1634931, "text": "Nursing 0700-1900\n\nNo significant event during shift.\n\nNeuro: Pt alert and oriented times three. Pt is on no sedation. Pt has left sided weakness 2/2 old CVA. Pt also has facial droop previous CVA. Pt able to move all extremeties.\n\nCV: No chest pain or chest discomfort noted or stated by the pt. afebrile, NSR 80-90's with no ectopy, NBP 90-113/60-70's with a mean 70-80's. No edema, good CSM, +PP. Hct 22.4 up from 21.6. Mg was repleted early in shift with 2gm.\n\nRespiratory: PH 7.48, Lung sounds clear in all with no SOB or DOE noted or stated by the pt. SpO2 97-100% on RA. RR 10-15.\n\nGI: Abdomen soft non-tender, PO intake improved, BS being taked every two hrs ranging 116 -209. Pt mushroom cath changed to a flexi seal. draining gold yellow liquid stool.\n\nGU: pt not voiding HD. pt to get HD in AM.\n\nSkin/other: Skin is intact, pt spoke to family, RN spoke to family. Attempt being made to change Rt femoral multilumen line over wire to a non-heparin line + HIT.\n\nPlan: change line over wire, BS ever two hrs. provide emotional support to both family and pt, HD on monday.\n" }, { "category": "Nursing/other", "chartdate": "2122-09-28 00:00:00.000", "description": "Report", "row_id": 1634932, "text": "Micu Nursing Progress Notes\nEvents: ultrasound of left upper arm showing increasing clot, started on argatroban.\n\nCardiac: B/P 143-158/84-90. K+ 4.6. Pt had an ultrasound of the upper left arm to evaluate her clot. She has 4+ edema of the left hand. The test showed that the known clot in the SVC was increasing in size. Argatroban was started at 12 midnight at 1mcg/kg/min. After 2hours of infusionher PTT was 77.2 which is in the goal range. Her PTT needs to be re-checked at 8am.\n\nResp: O2 sats on room air 98-100%, RR 15-21. Breath sounds clear.\n\nNeuro: Pt is alert and oriented, she MAE and is able to help with care. Follows commands.\n\nGI: Pt has a fair appetite, eating her dinner following the ultrasound. She requests apple juice when she is thirsty. Blood sugars 100-125, no hypoglycemia.\n\nGU: She is anuric, will be evaluated if she needs dialysis today.\n\nID: Remains afebrile, not on any antibotics.\n\nSocial: no contact with the family overnight.\n\nPlan: check PTT at 8am and adjust dose according to protocol, probable call out to the floor today.\n" }, { "category": "Nursing/other", "chartdate": "2122-09-28 00:00:00.000", "description": "Report", "row_id": 1634933, "text": "Nursing 0700-1900\n\nEvent: HD today ultrafiltrate 2.5L\n\nNeuro: Pt alert and oriented times 3. Pt able to move all extremeties. Pt has left sided weakness 2/2 old CVA. Pt is on no sedation. Pt also has facial droop previous CVA.\n\nCV: No chest pain or chest discomfort noted or stated by the pt. Pt afebrile, NSR/ST 90-100's with no ectopy. 115-150/60-70's with a mean of 80-100. Pt received Toprol XL 150mg PO in AM. Subsequently medication was dialyzed out today during HD. Pt was high in the afternoon (150-170/90's) pt received additional 150mg of PO Toprol XL at 1600. Medication time changed to HS starting tomorrow. Pt with increased clot size in left arm (SVC). argatroban @ 0.075.\n\nRespiratory: LS clear in all . SpO2 100% on RA. No SOB or DOE noted or stated by the pt.\n\nGI: Abdomen soft non-tender, PO intake good. BS 110-130 being done Q4hrs. Flexi seal in place draining yellow loose stool. Guiac negative.\n\nGU: pt not voiding HD. Pt had HD today ultrafiltrate 2.5L. Pt was given 1 unit of PRBC during HD.\n\nPlan: c/o to floor. HD -> , Monitor PTT next PTT due at 2200.\n" }, { "category": "Nursing/other", "chartdate": "2122-09-26 00:00:00.000", "description": "Report", "row_id": 1634929, "text": "npn 18:00\nPlease refer to ICU admit for additional pmh.\n*FULL Code\n\n*Patient c/o to floor this am, labs drawn, phosphorous continued to be low, as well as bs and pH moderately high. Sent back to MICU for close monitoring of Electrolytes. Central line placed on admit, currently has R femoral line, wnl.\nROS:\nNeuro: a/o x2 (date, self, and at times place). no c/o pain.\nCV: HR 90's, nsr, no ectopy, BP 1-teens-130's, Lopressor XR (am dose) given this afternoon by floor nurse. Afebrile\nResp: LS clear upper, diminished lower, RA o2 sat's 100%. No c/o sob.\nGi/GU: Taking po's (on floor) tolerated neutra phos repletion at 18:00, mushroom cath in place d/t yellow stool (?need for consecutive c-diff to be sent?) Anuric, HD m/w/f\nSkin: excoriated on buttocks, antifungal lotion applied. *L arm and L leg with edema, pulses palpable\nAccess: tlc R femoral\nSocial: Daughter hcp, no contact from family.\n" }, { "category": "Nursing/other", "chartdate": "2122-09-27 00:00:00.000", "description": "Report", "row_id": 1634930, "text": "MICU NURSING PROGRESS NOTES :\n\nPLEASE SEE CAREVUE & FHP FOR ADM HIST ,PMH & OBJECTIVE DATA.\n\nFULL CODE.\n\nALLERGIC TO HEPARIN.\n\nON CONTACT PRECAUTIONS FOR C- DIFF COLITIS, VRE.\n\nNO SIGNIFICANT EVENTS TILL TIME NOTED.\n\nNEURO : ALERT, ORIENTED X 2, FOLLOWS COMMANDS, HAS LEFT FACIAL DROOP & RESIDUAL LEFT SIDED WEAKNESS FROM CVA, WHEEL CHAIR BOUND AT BASELINE. DENIES PAIN. TOLERATES SWALLOWING REGULAR DIET(HAS SOME DIFFICULTY IN BITING HARD FOODS AS PER SWALLOW STUDY) & THIN LIQUIDS.\n\nRESP ; ON RA, SPO2 98 TO 100 %, LS CLEAR BILATERALLY. RR IN TEENS AND UNLABOURED. VBG DONE, PH WITHIN NORMAL LIMITS.\n\nCVS : NSR WITH NO ECTTOPY, SBP 99 TO 110'S, IV SODIUM PHOSPAHATE GIVEN OVER 6 HOURS, VIA RIGHT FEMORAL CENTRAL LINE CATH. LYTES MONITORED CLOSELY. CONTINUED ON NEPHROCAPS & NEUTRO PHOS PACKS. HAS 1 + EDEMA ON THE LEFT HAND.\n\nID : CONTINUES TO BE ON CONTACT PRECAUTIONS, T- MAX 98.9 AXILLARY. IS NOT ON ANY ANTIBIOTICS AT PRESENT. CULTURE RESULTS PENDING.\n\nGI : ABDOMEN SOFT, NON TENDER, BS PRESENT, MUSHROOM CATHETER CHANGED TO 36# , DRAINING LARGE LOOSE YELLOW STOOLS. HAD APPLE JUICE, DID NOT WANT TO EAT ANY FOOD DURING THE NIGHT. PLEASE SEE NUTRITION ORDERS FOR DIET.\n\nGU : IS ANURIC, LAST HD DONE ON WITH 1.6 LITS OF FLUID REMOVAL. RIGHT TUNELLED HD CATH PRESENT. HD 3 DAYS PER WEEK.\n\nENDO : FINGERSTICKS Q 2 HOURLY. PLEASE SEE CAREVUE FOR RESULTS. NO HYPOGLYCEMIC EPISODES THIS SHIFT.\n\nSOCIAL : SON & DAUGHTER VISITED. UPDATED ON PATIENT'S STATUS AND PLAN OF CARE BY MD. DAUGHTER GIVEN EXPLANATION ABOUT THE REFEEDING SYNDROME BY MD.\n\nPLAN :\nCONTINUE MONITORING PH. ? MD PLANS FOR CT HEAD.\n-CONTINUE MONITORING LYTES, S/P PHOS LEVELS.\n-? FINGERSTICKS Q 2 HOUR IF CONTINUES TO REMAIN WITHIN NORMAL OR ACCEPTABLE RANGE.\n-MONITOR FOOD CONTENT WHILE EATING TO AVOID ANOTHER EPISODE OF REFEEDING SYNDROME.\n-FOLLOW UP ON BLOOD & STOOL CULTURE RESULTS.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-09-25 00:00:00.000", "description": "Report", "row_id": 1634927, "text": "Micu Nursing Progress Notes\nEvents: Pt had dialysis with 1.6l removal, vital signs stable, called out to the floor.\n\nCardiac: B/P has been 107-129/60-70, HR 90-96. Her B/P while on HD was 92-95/70's. Her phos dropped to 1.0 again so she was repleted with 2 pkg's of neutra phos and was started on nephrocaps.\n\nResp: RR 16-24, O2 sats on 2l NC 100%. Changed to room air with O2 sats 99-100%. Breath sounds clear.\n\nGU: HD done today with 1.5L removed but there was difficulty with her B/P being low and they had to control it by NS boluses. She did not have any urine output today.\n\nGI: Fair appetite, eating some of her food from the kitchen. Swallow study was done which showed that she could swallow thin liquids bat did not have the strength to bite hard foods. She was ordered for soft solids but could have a regular diet if she wanted. She did not have any stool today. Abd is soft and non tender.\n\nEndo: Blood sugar at 8am was 70 just before she had breakfast. FS at 12n was 101 just before lunch.\n\nNeuro: She has a left sided facial droop from her prior CVA, she is alert and oriented, she is able to mae and help with her care.\n\naccess: pt has a tunneled dialysis catheter. She currently does not have any other venous access. The IV RN came up and was unable to get a line placed.\n\nSocial: No contact with her family today.\n\nPlan: continue to encourage food intake, pt is called out to the floor.\n" }, { "category": "Nursing/other", "chartdate": "2122-09-26 00:00:00.000", "description": "Report", "row_id": 1634928, "text": "Nursing Progress Note 0700-1900\n\nNeuro: A&Ox3, left facial drop and residual weakness from old CVA. Wheelchair bound at baseline Pt with c/o stomach cramps, diarrhea & skin irritation.\n\nResp: Lungs clear diminished at bases. RR 18-30 RR up with abdominal cramping sats 95-97 on RA\n\nCardiac: Tele SR-ST 80-100's. BP 88-120/60-70's, LLE with + 1 edema left worse than right. Trace palp pulses\n\nGI: Tolerating regular diet. + BS in4 quadrents. Pt with mutiple episodes of loose stool Mushroom catheter placed, draining large amounts of liquid brown stool. Spec sent\n\nRenal: ANuric at baselien on HD MWF. Tunnelled catheter CDI.\n\nID: tmax 100 rectal. Not currently on any antibiotics\n\nFEN/ENDOS: FS WNL, unalbe to draw labs this AM ? dialysis RN to come and access tunnelled line for labs\n\nSkin: Butccok excoriated from fecal inncontinece criticaid applied\n\nSocial: Full code, daughter called updated re:\n\nPlan:\n\n1. C/O to floor\n2. Monitor GI status\n3. COntinue to follow labs and FS\n4. Routien monitoring and care\n" }, { "category": "Nursing/other", "chartdate": "2122-09-28 00:00:00.000", "description": "Report", "row_id": 1634934, "text": "MICU Nursing Progress Note 1900-2200\n\nReceived pt in no apparent distress, no complaints of pain. Pt A&O x 3. Hemodynamically stable, received PM warfarin as ordered. PTT/HCT sent prior to transfer, results pending. Satting well on RA. Pt received .25mg ativan to facilitate transfer to CC7.\n" }, { "category": "Nursing/other", "chartdate": "2122-09-25 00:00:00.000", "description": "Report", "row_id": 1634926, "text": "Nursing Admit Note -0700\n\nThis is a 66 year old female with a very complex PMH that includes SLE, ESRD, HTN & CVA who presented to the EW with electrolyte abnormalities after dialysis. Upon presentation to EW Her phos was 0.4 & mag were 1.3. She had an episode of CP in the ambulance that resolved spontaneously. She had two episodes of profound hypoglycemia to 12 & 20 RX with D5. She was transferred to the MICU for further monitoring\n\nNeuro: A&Ox3, vague historian at times. Left facial drop and residual left sided weakness from CVA, wheelchair bound at baseline. Pt denies pain. Tolerates regular diet and thin liquids\n\nResp: Lungs clear diminished at bases. Sats 98-100% on 2 LNC, RR mid teens even and unlabored\n\nCardiac: Intermittent PAF over night, EKGS in chart pt asymptomatic, trace palp Pt/DP extremities cool to tough. Left with + 1 edema (per pt chronic)\n\nGI: Tolerating thin liquids. + BS in 4 quadrents, pt frail cachetic appearing. 2 loose light brown stools. Per family recently with increased PO intake and weight gain\n\nRenal: Anuric, old AV fistula on right arm without thrill or bruit. Tunnel dialysis line in left subclavin CDI. Scheduled for HD today\n\nAccess: pt with one PiV upon admission to MICU, but it quickly infiltrated. IV access unable to be obtained, mutiple attempts made in EW, by IV team and by MICU team (for central access) unsuccessful.\n\nFEN: FS low 100 range, phos continues to be low given neutra-phos x 2, Mag x 1, ca x 1 all PO.\n\nSkin: intact no issues\n\nID: afebrile no issues\n\nSocial: Daughter in to visit last evening udated by MICU team\n\nPlan:\n\n1. Q 2 hours FS, monitor labs closely\n2. HD this AM\n3. Monitor cardiac status re: new aflutter\n4. Routine ICU monitoring and care\n5. Emotional support to pt and family\n" }, { "category": "ECG", "chartdate": "2122-10-02 00:00:00.000", "description": "Report", "row_id": 208309, "text": "Sinus rhythm\nLeft anterior fascicular block\nEarly precordial QRS transition - is nonspecific\nDiffuse nonspecific T wave changes\nSince previous tracing of , may be no significant change but baseline\nartifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2122-09-30 00:00:00.000", "description": "Report", "row_id": 208310, "text": "Sinus rhythm with baseline artifact. Left axis deviation. Left\nanterior fascicular block. Diffuse non-diagnostic repolarization\nabnormalities. Compared to previous tracing of repolarization\nabnormalities persist, although they are somewhat less pronounced and a\nnon-diagnostic finding.\n\n" }, { "category": "ECG", "chartdate": "2122-09-25 00:00:00.000", "description": "Report", "row_id": 208311, "text": "Compared to prior tracing there is Q-T interval prolongation with T wave\ninversions inferiorly and anteriorly. Extensive inferior and anterior\nischemia, primary central nervous system event, and/or drug effect is possible.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2122-09-24 00:00:00.000", "description": "Report", "row_id": 208532, "text": "Normal sinus rhythm, rate 84. Left axis deviation. Non-specific\nanterolateral repolarization changes consistent with ischemia. Compared\nwith tracing of sinus tachycardia has given way to normal sinus rhythm.\nAlso, repolarization changes are more pronounced in the lateral precordial\nleads and less pronounced in the mid precordial leads.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2126-05-10 00:00:00.000", "description": "Report", "row_id": 1314023, "text": "Nursing Note Summary 07-1515:\n\n61yo w/o significant medical history admitted to MICUB this am from the cath lab. PT awoke this am @ 02 w/crushing CP without other symptoms. Went to OSH w/wife and noted to have w/ste in lead III and AVF. Transferred to for cath. In cath found to have 60% mid RCA, 100% mid to distal, 70% LCx, 70% LAD lesions. DES to the RCA placed. Procedure was complicated by pt with bradycardia treated with atropine with good result. Pt transferred to MICUB for closer monitoring.\n\nNeuro: Pt dozing intermittently throughout day. Oriented when awake. Pt with h/o alcoholic drinks/day and more on the weekends-pt on prn valium as needed and following CIWA protocol q4hours. CIWA scores @ 0. Pt no longer on leg movement restrictions. To maintain on bedrest for now.\n\nCVS: PT with bp 90-100's/40-60 in SB with occasional pvc's. PT also with ?junctional beats at times. K>4, mg 1.9. CCU team reviewed ekg's and rhythm strips with rounding. HR range 39-78. Asymptomatic when bradycardic-prn atropine on order and at bedside. PT with no episodes of CP or SOB this shift. Pt with episode of diaphoresis and nausea/vomiting x1-bp and hr stable through incident and ccu medical team at bedside rounding.-thought to be ?vagal response(hob up for lunch). Nausea subsided without treatment. EKG done post emesis and reviewed by team. CT surgery to consult this afternoon regarding three vessel disease and possible cabg. Integrilin gtt infusing @ 1.97 mcg/kg/min-to continue x18hours post cath(until 0045). Pt started on captopril and metoprolol-both held r/t hr and bp. Metoprolol dc'd after rounds r/t bradycardia and frequent ectopics. Pt also on heparin SQ. R.Groin site with dry dressing covered with a tegaderm. Initially with hematoma in cath lab post sheath removal. Hematoma resolved prior to admit to micu-no hematoma or echymosisi noted at site. Right leg warm with good pulses. Right leg remained immobile x6hours post procedure.\n\nPulm: Lungs clear on RA. o2sat >96%.\n\nGU: UO in adequate amounts via foley catheter. Maintenance fluid of d51/2 NS @ 100ml/hr to run x2.5L.\n\nGI: Pt on cardiac diet. Ate soup at lunch but with emesis. No futher episodes of n/v.\n\nSocial: wife and children at bedside throughout shift. Family updated by this rn and ccu team on status and plan to stay in icu overnoc for close monitoring and plan for possible cabg. Verbalized understanding. SW called at wife's request regarding insurance issues-in to see pt/family.\n" }, { "category": "Nursing/other", "chartdate": "2126-05-10 00:00:00.000", "description": "Report", "row_id": 1314024, "text": "Pt c/0 chest discomfort @ 1730. Pt stated this discomfort had been present on and off since this afternoon. ekg done with no apparant change from previous. PT also c/o HA. Dr. notified of above event and that pt continues to have frequent pac,pvc's. PRN order received for tylenol and morphine. Pt denied pain post ekg in chest. Prn tylenol given for HA. Pt dozing now. To monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2126-05-11 00:00:00.000", "description": "Report", "row_id": 1314025, "text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-hr has been 40-70 sb/nsr with rare-freq pvcs.pt is asymptomatic with dips in hr. bp has been 122-80/50's. no c/o chest pain or pressure. captopril was held x1, then given a few hours later.no nausea or diaphoresis. integrilin d/cd at 0045 as ordered.\n\nRESP-lungs are clear. on room air o2 sats are 98-100%, no c/o SOB.\n\nNEURO-a+o x 3, cooperative. has been sleeping in long naps.no sleeping meds or valium given.awakes easily.no \"jitters\".\n\nF/E-receiving the last of the IVF. taking sips of h2o with meds.has been voiding large amts clear light yellow urine.am labs are pnd.\n\nGI-had a large OB- stool on bedpan. I think he will try breakfast this am.abd is soft with positive bowel sounds\n\nVASC-R groin site is dry and intact. R foot warm with easily palpable pulses. L foot cooler with pulses more difficult to palpate/doppler.HO aware, she evaluated.he can wiggle toes,etc.\n\na-uneventful night\n\nP- will finish up ivf and encourage po fluids.check am labs.monitor for further bradycardia.watch L foot. careplan as per cardiology team.\nassess for signs withdrawal-valium prn.\n" }, { "category": "Echo", "chartdate": "2126-05-10 00:00:00.000", "description": "Report", "row_id": 79114, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. s/p MI. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 205\nBSA (m2): 2.11 m2\nBP (mm Hg): 110/60\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 09:56\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate\nregional LV systolic dysfunction. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. There is moderate regional left ventricular systolic dysfunction\nwith akinesis of the inferior wall and hypokinesis of the infero-septum and\ninfero-lateral walls. No masses or thrombi are seen in the left ventricle.\nRight ventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are structurally normal. Mild to moderate (+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation. There is borderline pulmonary artery systolic hypertension. There\nis no pericardial effusion.\n\nIMPRESSION: Moderate regional LV systolic dysfunction c/w CAD.\n\n\n" }, { "category": "ECG", "chartdate": "2126-05-10 00:00:00.000", "description": "Report", "row_id": 192635, "text": "Sinus bradycardia with occasional atrial premature beats. Possible acute\ninferior myocardial infarction. Compared to the previous tracing of no\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-05-10 00:00:00.000", "description": "Report", "row_id": 192636, "text": "Sinus rhythm. Supraventricular extrasystoles. Probable old inferior myocardial\ninfarction. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2189-12-29 00:00:00.000", "description": "Report", "row_id": 1505303, "text": "CCU Nursing Admit/Progress Note 8pm 1/10-7am \nS: I guess I can stay here for a few days.\n\nO: Rec'd 62yom via cath lab s/p Stent x1 to L main and stent x3 to LAD with l fem IABP placement and R fem swan. Pt was know 3vd with +3mr awaiting CABG/Valve replacement with an EF 20-25%, when he developed cp, SOB and abd pain x 2 weeks. See admit note for further PMH/data\n\nCV - HR 80's NSR with rare single PVC's. K+4.9 at 1130pm and Magnesium at 1130pm 1.9 and was not repleted. AM labs pnd.\nIABP via l groin is d/i and is 1:1 with fair augmentation and point unloading. MAPs are in the 80's.\nSwan ganz via r groin site is d/i and PAP are 60-50/29-19 with no further diuresis since 2pm . Dobutamine cont 5mcgs/kg/min. CO/CI improved from 6.4/2.5 to 8.8/3.5. No CVP port for measurement.\nIntegrellin cont 2.14mcgs/kg ant was stopped at 7am. Heparin cont 800u/hr with PTT 42 which is therapeutic per cath lab fellow.\nPulses d/d bilaterally with nl sensation. Color is pale and feet are cool, which is pt's nl. Bilat knee immobilizers in place. Pt is instructed to lie flat and not to lift head. Bed placed in reverse t- for comfort.\n\nResp - Pt has productive cough, which he states is chronic. Admits to ppd smoking. Exp wheeze audible l lung and rales r base. O2 sat down to 85 when on RA, although pt is lying flat in bed.\n\nGI - Abd soft with +bs and no stool. Appetite good.\n\nGU - No futher diuresis as per above. Pt wanting to drink. u/o 80-140cc/hr. Post cath IVF 1 liter absorbed.\n\n - PT is IDDM although bs are very labile. FS at 11pm was unreadable on glucometer. Lab value 480. Insulin gtt started after 7 unit reg insulin bolus. Titrated up to 15units/hr and is slowly being titrated down. See careview for all bs and changes in insulin dose.\n\nSocial - Wife, daughter and grandson with pt this past evening and are aware of progress/plan of care. Pt states that home is very stressful with his grandson living with him. He keeps a close eye on him and is worried about him since pt is in the hospital. Encouraged verbalization. Pt is a retired heavy machine operator who now plows snow for extra money. Is very concerned about money, but does realize that he may need to take a break from his snow plowing duties.\n\nTeaching/ Pt is continually asking for fluids to drink. Reminded that we are giving him lasix so as to pull off fluid. He wants to know when he can drink. He doesn't seem to understand the coorelation between lasix and drinking. He drinks alot of water at home.\nPt informed when insulin drip started. Pt states that he can't understand why his sugar is so high when he watches his salt intake. His dose of insulin at home changes each day, but he can't explain why it changes.\n\nA/P: 62yo with successful LMain and LAD stents with good CO/CI on IABP and Dobutamine. Cont current plan of care IABP and Dobutamine, checking frequent numbers during weaning. Further diuresis for PAD up to 20.\nFrequent BS checks and titrate insulin as able.\nDiabetic\n" }, { "category": "Nursing/other", "chartdate": "2189-12-29 00:00:00.000", "description": "Report", "row_id": 1505304, "text": "CCU Nursing Admit/Progress Note 8pm 1/10-7am \n(Continued)\n, smoking cessation and cardiac teaching with wife present, as pt's understanding is questionable.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-29 00:00:00.000", "description": "Report", "row_id": 1505305, "text": "PT AWAITING CABG/MVR\n\nST, ONE RUN VT 7AM, NO ECT SINCE . MAPS 70S ON IABP 1TO1,MIN AUGMENTATION .PTT 42 ON 800U HEPARIN .PAD 19 TO 20.CI 4,6 ,DOBUT WEANED TO 2.4MIC.STARTED ON CAPTOPRIL .DISTAL PULSES BY DOPPLER.GROIN C/D .\n BS CL SAT 95 ON 5L NP ,90 ONH RM AIR ,\nEATING WELL. ON INSULIN GTT ,BS 150 TO 76,CURRENTLY ON 3U/HR .\nDIURESED C 60MG LASIX ,GOAL NEG 500 .\nALERT,COOPERATIVE,PERCOCETTE X1 C RELEIF.\nAWATING TO HEAR IF PT IS GOING TO SX THIS WEEK ,IF NOT DC IABP TOMORROW,IF YES DC DOBUTAMINE ,KEEP PUMP TILL OR\n" }, { "category": "Nursing/other", "chartdate": "2189-12-30 00:00:00.000", "description": "Report", "row_id": 1505306, "text": "CCU progress note 7p-7a\n\nUneventful night. . remains 1:1 on IABP. For CT scan + ECHO this morning. Surgery will decide re: wether pt will go for surgery or not depending on CT + Echo results.\n\nNEURO: family in visiting all evening. pt anxious re: surgery. he knows his poor prognosis w/ + without surgery. slept in naps.\n\nID: afebrile. WBC 11.5. no abx.\n\nRESP: LS clear, dim. O2 5L n/c. sats >98%.\n\nCARDIAC: SR 80-90s. no vea. MAPs 80s. IABP 1:1. good waveform. L fem site D+I. R fem PA line intact. PA 50/21. PA sats 68% CO 8 CI 3.23. no c/o CP or discomfort. Heparin @ 800u/hr. Dobutamine continues @ 2.4mcg/k/min + Captopril po TID. ?increase next dose. 2 peripheral IVs.\n\nGI/GU: foley patent. diuresed @ MN w/ Lasix 40mg IVP. large results. urine pink in colour. abd soft +BS. no BM.\n: FS Q1H for INSULIN gtt. see flowsheet.\nI/Os: Daily Weights. 1500cc FLUID RESTRICTION. pt wants to drink all the time, he wants to replace the fluid he diuresed!\n\nPLAN: q1h FS. strict I/O + fluid restriction. further diuresis today. ^next dose captopril. pt teaching re: diet, fluid restrictions, diabetes, cardiac, smoking cessation. emotional support re: anxiety re surgery decision. Echo + CT scan today. ?d/c IABP if no surgery, if surgery to be scheduled wean off dobuta + keep IABP until surgery.\n" }, { "category": "Nursing/other", "chartdate": "2190-01-01 00:00:00.000", "description": "Report", "row_id": 1505311, "text": "CCU Nursing Progress Note\nS-\"I keep on coughing, is that from my smoking?\"\nO-Neuro-alert and oriented x2-3, alittle disoriented this morning from IV ativan last night. Angry about being in bed so long and wants to sit on edge of bed. Also anxious about doing too much too soon. Needs to be in control.\nCV- remains on dobutamine infusion at 2.5mcg/kg/min, Hemodynamics PAD 16-18. Tolerating captopril 25mg TID and isordil 10mg TID. Right fem PA catheter d/c'd at 1500. Received lasix/aldactone po this am and diuresing well. HR 91-100 NSR with occ PVC, received digoxin load .5mcg(.25mg x2 IVB) today. No c/o chest pain but easily SOB with minimal activity.\nResp-LS decreased BS bases with few exp wheezes. Freq productive cough thick tan secretions. O2 3lnp with sats 94-96%. This am O2 sats dropped to 87% on RA. Pt does not like to wear nasal cannula all the time.\nID afebrile with WBC 11.6\nGI-appetite good- despite complaints about not having salt and sugar. abd soft non tender. LBM 3 days ago.\n- off insulin gtt receiving SSRI with blood sugars still elevated 198-378. Increased evening NPH dose to 18u and adjusted SSRI. Anxious to talk to someone from about his diabetes.\nGU- foley draining 50cc/hr light amber urine. Last IV lasix (100mg). Remains on fluid restriction.\nSkin-reddend coccyx 4cm around, able to turn in bed now without femoral line. Noted right leg cool and right leg warm, pedal pulses are dop/dop.\nSocial-wife and children into visit this evening.\nA/P-3VD/3+MR refused for CABG/MVR, now s/p LM and LAD stent requiring IABP and dobutamine for LVEF 15-20%.\nContinue dobutamine infusion for \"holiday\" as po medications are adjusted. Goal MAP >65.\nMonitor urine output Goal 1 liter negative.\nStart teaching for DM, smoking cessation and CHF.\nOOB in am as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2190-01-02 00:00:00.000", "description": "Report", "row_id": 1505312, "text": "NURSING PROGRESS NOTE\nS: \"WHAT IS MY TOTAL OUT?\"\n\nO: NEURO: PT. ANXIOUS AT TIMES CONCERNED ABOUT DISEASE PROCESS AND TREATMENTS. MOVING ALL EXTREMITIES WELL. TURNS IN BED WITH MIN ASSISTANCE. PT. ALERT AND ORIENTED X3. FAMILY IN TO VISIT EARLIER IN EVENING. ASKING APPROPRIATE QUESTIONS CONCERNING HOSPITALIZATION AND TREATMENTS.\n\nCV: CONT ON DOBUT GTT, WEANING NOW ON 2 MCG/KG/MIN. HR 85-87 SR WITH OCC PVC. RIGHT GROIN C&D, TRANSPARENT DRESSING INTACT. FEET WARM TO TOUCH. DENIES C/O CP.\n\nRESP: LUNGS CLEAR IN UPPER AIRWAYS, DIMINISHED AT BASES. COUGHING AND RAISING MOD AMTS OF THICK TAN-GREEN SPUTUM. BECOMES SOB WITH MINIMAL EXERTION (TURNING, SITTING UP). O2 3L NC, ENCOURAGED TO WEAR O2 (AS HE TAKES OFF O2 NC AND O2 SAT MONITOR FREQUENTLY).\n\nGU: FOLEY INTACT. DRAINING CLEAR YELLOW URINE IN GOOD AMTS. SEE FLOWSHEET FOR I/O DATA. CONT TO RECEIVE DAILY LASIX PO.\n\nGI: APPETITE FAIR. LIMITING FLUID INTAKE. NO BM OVERNIGHT BUT PASSING FLATUS. ABD SOFT.\n\n: COVERING ELEVATED BLOOD SUGARS WITH SSRI. ASKING FOR DOCTORS TO PT. BEFORE DISCHARGE AS PT. IS NEW TO INSULIN.\n\nA/P: STABLE S/P STENT PLACEMENT TO LM. NOT A SURGICAL CANDIDATE FOR CABG. MAXIMIZING MEDS AND DISCUSSING OTHER TREATMENT OPTIONS FOR CHF, LOW EF. WEAN DOBUT AS TOL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-31 00:00:00.000", "description": "Report", "row_id": 1505309, "text": "CCU Progress Note:\n\nS- \"I'll do anything you want so long as you get me home!\"\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR-ST occ PVC's- HR 94-114- IABP D/C'd @ 1300- L groin dsg D&I- no hematoma or oozing- (+) DP & PT pulses bilaterally by doppler- PA line remains R groin- PAS 38-50 PAD 16-22 while on IABP- Once d/c'd\nPAS 50-64 PAD 27-32- dobutamine gtt D/C'd @ 1400- CO 6 CI 2.4 @ 1500- c/o difficulty breathing & vague CP- EKG done T wave invertions noted in lateral leads- lasix 60mg IV & MS 2mg IV given with effect- dobutamine gtt restarted @ 1530 @ 2.4mcq/kg/min- diuresing well @ present- K 4.5- Mg 1.8 Mg sulfate 2gms IV given- Hct 34\n\nresp- In O2 2L via NC- lung sounds with I&E wheezes noted L upper lobe & diminished @ bases bilaterally- resp rate 20-28- SpO2 92-98%.\n\ngi- abd soft (+) bowel sounds- taking PO well- insulin gtt D/C'd @ 1100- fingerstick @ 12noon 92- fixed dose NPH ordered along with insulin sliding scale- fingerstick @ 1700 294- NPH & reg insulin given as ordered- no BM today.\n\ngu- foley draining hematurea to yellow colored urine- diuresing well from lasix- (-) 1500cc since 12 am- BUN 23 Crea .8- Pt was started on\nlasix 40mg PO & spironolactone 25 mg PO @ 12noon- However, extra lasix was needed once off IABP.\n\nneuro- seems depressed- talking frequently about his poor prognosis- A&O X3- moving all extremities- cooperative- follows command.\n\nA- elevated PAD off IABP requiring extra lasix & morphine\n\n Pt to start on Ntg gtt- con't dobutamine gtt @ 2.4mcq/kg/min- repeat lasix 40mg IV- repeat lytes & replete as needed- EKG with c/o CP- T 100 po- pan culture if temp spike- offer emotional support to Pt & family- keep them updated on plan of care.\n\n" }, { "category": "Nursing/other", "chartdate": "2190-01-01 00:00:00.000", "description": "Report", "row_id": 1505310, "text": "Nursing Progress Note\n\nS: I don't have any pain.\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm with occ pvc's. Remains on Dobutamine at 2.4mcgs/kg/min and Nitro at 30mcgs/min. Denies any chest pain or shortness of breath. CO/CI remain stable at 6.32/2.54. PAD 11-21. Started on Digoxin IV given .5mg x's 1. L groin is C&D without evidence of hematoma. Distal pulses by doppler.\n\nResp: Pt has productive cough raising mod amts of thick tan sputum. O2 sat 94-96% on 2 l NP. Lungs with scattered rhonchi at times.\n\nNeuro: Pt is alert and oriented. Anxious to bet OOB when swan is dc'd. Pt requesting Trazodone and ativan for sleep. Slept in naps throughout the night.\n\nGU/GI: Good diuresis from 40mg lasix given at change of shift. Neg 3 liters for the day. Am labs are pending. Abd is soft with bowel sounds present.\n\n: Remains off insulin drip with SS coverage for elevated bld sugars. To start on fixed dose of insulin this am.\n\nA&P: Hemodynamically stable while on dobutamine with good diuresis from lasix. Cont to assess hemodynamics titrate captopril as tolerated. Lasix prn. ? dc swan.\n" }, { "category": "Nursing/other", "chartdate": "2189-12-30 00:00:00.000", "description": "Report", "row_id": 1505307, "text": "62 YR OLD C EF 20 TO 25 % P MULTIPLE MIS ,AWAITING CABG AND MVR HAD CP ,TAKEN TO CATH LAB 1/10,3 STENTS TO LAD,1 STENT TO L MAIN .IABP PLACED,DOBUTAMINE GTT STARTED ,KEPT ON BOTH TILL DETERMINED IF PT WAS CANDIDATE FOR SX OR TRANSPLANT ,P CT SCAN AND ECHO HE IS NOT. PLAN TO DC PUMP AND KEEP PT ON DOBUTAMINE HOLIDAY .PT HAS NOT BEEN INFORMED.\n\nTODAY SR TO ST C OCC PVCS .MAPS 60 TO 70S .CI 3.1 SVO268 .HEPARIN TURNED DOWN TO 700U FOR PTT OF 70 .PUMP 1TO 1 .BILATERAL PEDALS BY DOPPLER .PAD 18 TO 20 .PLAN TO WEAN IABP 2AM .\n\nBS CL,SAT 91 TO 94 ON RM AIR . 99 ON 2L .\n\nGOOD APPETITE ,POS BS ,NO STOOL.\n\nON INSULIN GTT BS 63 TO 157 ,ADJUSTED ACCORDINLY\n\nDIURESED NEG 2L ,ON 1500CC FLUID RESTRICTION ,URINE PINK .\n\nT MAX 99.2\n\nPT ANXIOUS ABOUT DESCISION CONCERNING SX,WILLBE VERY UPSET .HE IS STILL SMOKING OCCASSIONALLY .HAS BEEN RECENTLY DX AS DM AND IS NOT REGULATED ,NEEDS TEACHING\n\nK.PTT,SVO2 PENDING\nEMOTIONAL SUPPORT\n\n" }, { "category": "Nursing/other", "chartdate": "2189-12-31 00:00:00.000", "description": "Report", "row_id": 1505308, "text": "Nursing Progress Note\n\nS\"I think I would still llike to have the surgery.\"\n\nO: Please see flow sheet for objective data. Conts on Dobutamine at 2.4mcgs/kg/min and Heparin at 700u/hr. Tele sinus rhythm with occ pvc's. IABP weaned down from 1:1 to 1:2 to 1:3. Please see flow sheet for CO/CI. MVO2 77 throughout the night. Presently IABP back at 1:1. Pt denies chest pain.\n\nResp: Lungs dminished at bases other wise clear. Productive cough raising tan sputum. O2 sat 94-97%.\n\nNeuro: Pt is alert and oriented. Pt appropriately upset about not being surgical canidate. Pt sleeping throughout the night after his family left.\n\nGU/GI: Pt maintained on fluid restriction. Abd is soft with bowel sounds present. Foley draining pink to red tinged urine. HUO 70-90. No lasix this shift. 24hr urine reamins intact.\n\n: Conts on Insulin drip for BS coverage. Drip off for several hrs with BS 80-90's. Restarted at 1u and increased to 3u/hr.\n\nSocial: Multiple family members here at the beginning of the shift. All spoke with MD about present POC.\n\nA&P: Tolerated IABP wean well overnight. Plan is to dc some time today. Heparin conts at 700u/hr. Titrate ace as BP tolerates. Diuresis as needed.\n" }, { "category": "Echo", "chartdate": "2189-12-30 00:00:00.000", "description": "Report", "row_id": 60123, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment. Assess MR on and off IABP .\nHeight: (in) 70\nWeight (lb): 154\nBSA (m2): 1.87 m2\nBP (mm Hg): 100/67\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 13:01\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nStudy performed with and without IABP support.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand/or RV.\n\nLEFT VENTRICLE: Severely dilated LV cavity.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; basal anteroseptal - akinetic; mid anteroseptal - akinetic; basal\ninferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic;\nanterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic;\nlateral apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left ventricular cavity is severely dilated. Resting regional wall motion\nabnormalities include diffuse hypokinesis with anteroseptal and apical\nakinesis, basal to mid inferior akinesis and basal inferolateral akinesis. No\napical thrombus seen (cannot definitively exclude). Right ventricular chamber\nsize is normal. Right ventricular systolic function is borderline preserved.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. Moderate (2+) mitral regurgitation is seen. Mitral\nregurgitation increases to moderate to severe (3+) with the intra-aortic\nballoon pump off. There is a trivial/physiologic pericardial effusion.\n\nCompared to the prior transesophageal study of , left ventricular\nsystolic function now appears more depressed and mitral regurgitation (with\nthe IABP off) is similar.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-26 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 851530, "text": " 11:15 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Eval for gallstones\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with elevated LFTs, lipase\n REASON FOR THIS EXAMINATION:\n Eval for gallstones\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated LMPs and lipase.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture, and\n without focal hepatic masses. There is no intra- or extrahepatic biliary\n ductal dilatation. The pancreas is slightly echogenic. There is a tiny\n amount of free fluid adjacent to the liver. There are two simple cysts within\n the right kidney, the larger in the lower pole measuring approximately\n 2.3 x 1.7 x 1.8 cm. The remainder of the right kidney is normal. The\n gallbladder is without stones, wall edema, distension, or paracholecystic\n fluid. The gallbladder contains a small fold. The common bile duct is normal\n measuring 2 mm.\n\n IMPRESSION\n 1. No evidence of cholelithiasis or cholecystitis.\n 2. Simple right renal cyst.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851808, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess chf\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with chf s/p Left main stent and IABC please asess for change\n in chf\n REASON FOR THIS EXAMINATION:\n please assess chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 62-year-old male with CHF.\n\n FINDINGS:\n\n An intraaortic balloon pump terminates with its distal tip overlying the\n posterior left seventh rib. A Swan-Ganz catheter terminates with its distal\n tip in the region of the main pulmonary artery outflow tract. Fullness of\n both hila presumably reflecting hilar adenopathy as seen on a CT from\n is present. The lungs are clear with no failure, pulmonary\n parenchymal consolidation, or pleural effusion. The extreme portions of both\n lung apices are excluded. No osseous abnormalities are seen.\n\n IMPRESSION:\n\n Lines in satisfactory position with clear lungs and no evidence of failure.\n Both hila are enlarged, a finding that likely reflects adenopathy as seen on a\n CT from .\n\n\n" }, { "category": "Radiology", "chartdate": "2190-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852293, "text": " 1:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with chf s/p Left main stent, now with productive cough\n with sputum, low grade fevers.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 62-year-old with CHF. Evaluate for infiltrates.\n\n An AP portable study of the chest is compared to the prior study of 2 days\n earlier. The right femoral vein Swan-Ganz catheter remains in place. The tip\n is in the main pulmonary artery. Cardiomegaly is noted. The lungs are clear.\n There are no evidences of pleural effusions or pneumothoraces.\n\n IMPRESSION:\n\n Cardiomegaly but no evidence of active diseases in the lungs. A femoral vein\n Swan-Ganz catheter in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-27 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 851536, "text": " 1:26 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: eval for pe\n Admitting Diagnosis: CHEST PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cp, sob\n REASON FOR THIS EXAMINATION:\n eval for pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk 3:25 AM\n no pe. mediastinal and hilar lymphadenopathy. no pna\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n CLINICAL HISTORY: Chest pain.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial images through the chest prior to and following the\n administration of IV contrast. Coronal and sagittal reformatted images were\n obtained.\n\n CONTRAST: Optiray was administered due to diabetes and rapid rate bullous\n injection.\n\n CTA OF THE CHEST:\n\n FINDINGS: There are no filling defects in the pulmonary arteries to indicate a\n pulmonary embolism. There are no pleural effusions. There are dense coronary\n artery calcifications along the LAD and RCA and arthrosclerotic calcification\n of the descending thoracic aorta and aortic arch. There is a trace fluid in\n the pericardial space. No pathologically enlarged axillary lymph nodes. There\n is a 1.3-cm prevascular lymph node as well as several smaller prevascular\n lymph nodes. There are several -mm pretracheal lymph nodes. There are\n several, approximately 1-cm pretracheal and precarinal lymph nodes. There are\n several 1.1-cm AP window lymph nodes. The largest precarinal lymph node\n measures 1.3- cm. No pathological hilar lymph nodes. There are emphysematous\n changes, particularly at the right lung apex. There is a small, round\n calcified nodule in the left upper lobe consistent with a granuloma. There are\n areas of minimal pleural thickening at the right lower lobe periphery, which\n could be atelectasis. The airways are patent to the level of the segmental\n bronchi bilaterally. Limited views of the upper abdomen show an unremarkable\n liver and spleen.\n\n REFORMATTED IMAGES: These show normal pulmonary arteries.\n\n BONE WINDOWS: No suspicious osteolytic or sclerotic lesions.\n\n IMPRESSION: No pulmonary embolism. Mediastinal lymphadenopathy.\n\n\n (Over)\n\n 1:26 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: eval for pe\n Admitting Diagnosis: CHEST PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2189-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851524, "text": " 9:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with sob\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Shortness of breath. History of CHF.\n\n CHEST, AP PORTABLE:\n\n COMPARISON: Comparison is made to prior study of .\n\n FINDINGS: There are no pleural effusions or infiltrates. No pneumothorax or\n pulmonary edema. The cardiac silhouette is enlarged, and appears larger\n than previously.\n\n IMPRESSION: 1. Enlarged cardiac silhouette (see above)\n 2. No CHF.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851962, "text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for CHF\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with chf s/p Left main stent and IABC please asess for change\n in chf\n REASON FOR THIS EXAMINATION:\n Please evaluate for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 62-year-old man with congestive heart failure status post left\n main stent placement and intraaortic balloon pump. Please assess for\n congestive heart failure.\n\n Comparison is made with a prior AP view of the chest dated .\n\n SINGLE AP VIEW OF THE CHEST: An inferior approaching Swan-Ganz catheter is\n seen with the tip in the area of the pulmonary outflow tract. There has been\n interval removal of an intraaortic balloon pump. There is no evidence of\n pneumothorax.\n\n When comparison is made with a prior study dated , there has been no\n change in the fullness surrounding bilateral hila, and presumably reflecting\n adenopathy in this region as evidenced on CT dated . The pulmonary\n vasculature is normal. The cardiac, mediastinal, and hilar silhouettes are\n stable. The left costophrenic angle is not seen. There is no right-sided\n pleural effusion. The surrounding soft tissue and osseous structures remain\n stable.\n\n IMPRESSION:\n\n 1) Interval removal of an intraaortic balloon pump without evidence of\n pneumothorax.\n 2) No evidence of congestive heart failure.\n 3) No new infiltrates, consolidations, or effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-30 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 851985, "text": " 9:28 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate anatomy, for pre-transplant workup.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cp, sob, 3VD and MR, here awaiting possible CABG vs.\n cardiac transplant.\n REASON FOR THIS EXAMINATION:\n Please evaluate anatomy, for pre-transplant workup.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain and shortness of breath. The patient awaiting CABG or\n cardiac transplant.\n\n TECHNIQUE: CT imaging of the chest without intravenous contrast. Additional\n reconstructed at high-resolution images were also obtained.\n\n CT OF THE CHEST WITHOUT CONTRAST: A Swan-Ganz catheter passes through the IVC\n and terminates within the left main pulmonary artery. Intraaortic balloon\n pump is in somewhat low position with its distal tip at the level of the\n carina. The balloon of this device is inflated in the region of the origin of\n the celiac axis. Coronary artery calcifications are seen. A small\n pericardial effusion is identified. The heart is enlarged. Mediastinal lymph\n nodes are identified that are enlarged within the pretracheal and peritracheal\n regions.\n\n Emphysematous change is seen within both lung apices. There is a minimal\n amount of ground-glass opacity suggestive of edema within both upper lobes.\n Bronchiectasis and peribronchial opacity is identified within the right lower\n lobe posteriorly. A lesser amount of opacity is seen within the posterior\n portion of the left upper lobe near the fissure. Small pleural effusions are\n seen (right greater than left).\n\n Within the visualized portions of the upper abdomen, a low attenuation lesion\n is seen within the anterior right kidney that cannot be further characterized\n on this noncontrast study but likely represents a simple cyst. Within the\n visualized portions of the upper abdomen, limited views of the liver, spleen,\n and adrenal glands are within normal limits.\n\n Bone window show no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n\n 1) Bronchiectasis and peribronchial opacity that is most prominent within the\n posterior right lower lobe with associated small effusions. This finding is\n suggestive of pneumonia. Atelectasis is a less likely consideration. A\n similar lesser amount of opacity is seen within the posterior left upper lobe.\n\n 2) An intraaortic balloon pump is in place with its distal tip below the\n carina. The inflated balloon in place at the origin of the celiac axis.\n\n (Over)\n\n 9:28 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate anatomy, for pre-transplant workup.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3) Unchanged enlarged mediastinal lymph nodes.\n\n 4) Emphysema.\n\n 5) Cardiomegaly and pericardial effusion.\n\n These findings were reported to the ordering physician . at the time\n of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852114, "text": " 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please asess for change in chf and placement of IABC tip.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with chf s/p Left main stent and IABC\n REASON FOR THIS EXAMINATION:\n please asess for change in chf and placement of IABC tip.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62 year old man with CHF, IABP.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the prior chest radiograph dated .\n\n FINDINGS: The IABP tip is identified in the descending aorta, unchanged\n compared to the prior study. Central venous line from IVC is noted. Again\n note is made of mild cardiomegaly. Bilateral apices are not included in the\n present study. The mediastinal and hilar contours are unchanged compared to\n the prior study. Bilateral lungs are clear. Atelectasis vs. consolidation in\n the right lower lobe is noted. No evidence of CHF is noted.\n\n IMPRESSION: Tubes and lines as described above. Opacity in the right lower\n lobe, representing either atelectasis vs. consolidation in right lower lobe.\n\n" }, { "category": "ECG", "chartdate": "2189-12-26 00:00:00.000", "description": "Report", "row_id": 108941, "text": "Sinus rhythm\nLeft atrial abnormality\nIntraventricular conduction delay - probable left bundle branch block\nDiffuse ST-T wave abnormalities - may be due to left bundle branch block but\ncannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , ST-T wave changes more prominent\n\n" }, { "category": "ECG", "chartdate": "2189-12-30 00:00:00.000", "description": "Report", "row_id": 108893, "text": "Sinus tachycardia\nLeft atrial abnormality\nIntraventricular conduction delay - probably left bundle branch block\nSince previous tracing of , sinus tachycardia present\n\n" }, { "category": "ECG", "chartdate": "2189-12-29 00:00:00.000", "description": "Report", "row_id": 108894, "text": "Sinus rhythm\nLeft atrial abnormality\nIntraventricular conduction delay - probable left bundle branch block\nDiffuse ST-T wave abnormalities - may be due to left bundle branch block but\ncannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2189-12-28 00:00:00.000", "description": "Report", "row_id": 108895, "text": "Sinus rhythm\nLeft atrial abnormality\nIntraventricular conduction delay - probable left bundle branch block\nDiffuse ST-T wave abnormalities - may be due to left bundle branch block but\ncannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2196-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177319, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position.\n Unchanged borderline size of the cardiac silhouette, unchanged mild pulmonary\n edema. The lung bases are not included on today's image.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-01-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177519, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with chronic emphysema and pneumonia, s/p extubation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with chronic emphysema and pneumonia, query\n change.\n\n TECHNIQUE: Portable supine chest radiograph submitted for review compared\n with the prior study of .\n\n FINDINGS: The patient has been extubated in the interval and an NG tube\n removed. The bilateral basilar airspace opacities have improved slightly in\n the interval since the prior study, particularly in the right base. No new\n pulmonary parenchymal opacities identified.\n\n IMPRESSION: Slight interval improvement in the predominantly basal pulmonary\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2196-01-06 00:00:00.000", "description": "P EMERG BILAT LOWER EXT VEINS PORT", "row_id": 1177211, "text": " 1:24 PM\n EMERG BILAT LOWER EXT VEINS PORT Clip # \n Reason: ?DVT. Portable U/S please.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with acute on chronic respiratory failure, r/o PE.\n REASON FOR THIS EXAMINATION:\n ?DVT. Portable U/S please.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 7:10 PM\n No evidence of DVT in the legs bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, assess for PE and DVT.\n\n TECHNIQUE: Noninvasive ultrasound evaluation of the bilateral lower\n extremities.\n\n COMPARISONS: None available.\n\n FINDINGS: -scale and color doppler son evaluation of the\n bilateral lower extremities demonstrates appropriate compressibility and flow\n within the common femoral, superficial femoral and popliteal veins. Doppler\n evaluation of the posterior tibial and peroneal veins bilaterally demonstrates\n good flow.\n\n IMPRESSION:\n No evidence of DVT in the legs bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2196-01-06 00:00:00.000", "description": "P EMERG BILAT LOWER EXT VEINS PORT", "row_id": 1177212, "text": ", MED 1:24 PM\n EMERG BILAT LOWER EXT VEINS PORT Clip # \n Reason: ?DVT. Portable U/S please.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with acute on chronic respiratory failure, r/o PE.\n REASON FOR THIS EXAMINATION:\n ?DVT. Portable U/S please.\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in the legs bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2196-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177100, "text": ", EU 2:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with COPD exac, intubated\n REASON FOR THIS EXAMINATION:\n please eval acute process\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of DVT in the legs bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2196-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177099, "text": " 2:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with COPD exac, intubated\n REASON FOR THIS EXAMINATION:\n please eval acute process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 5:01 PM\n PFI: No evidence of DVT in the legs bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with COPD exacerbation.\n\n COMPARISON: None available.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are well expanded and show a right middle and left lower lobe\n opacity as well as bilateral interstitial opacities and pulmonary vascular\n prominence. The cardiomediastinal silhouette and hilar contours are normal.\n The left costophrenic angle is excluded from view. A right-sided effusion is\n present. An ET tube terminates appropriately within the mid thoracic trachea.\n An NG tube passes out of view below the diaphragm.\n\n IMPRESSION:\n\n Bilateral lower lobe opacities may represent pneumonia. Mild congestive heart\n failure. Tubes are appropriate in position.\n\n" }, { "category": "Echo", "chartdate": "2196-01-06 00:00:00.000", "description": "Report", "row_id": 92675, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 64\nWeight (lb): 250\nBSA (m2): 2.15 m2\nBP (mm Hg): 130/59\nHR (bpm): 103\nStatus: Outpatient\nDate/Time: at 16:16\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. TDI E/e' >15, suggesting PCWP>18mmHg.\nAbnormal systolic flow contour at rest, but no LVOT obstruction.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\nventilator.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and global\nsystolic function (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). There\nis an abnormal systolic flow contour at rest, but no left ventricular outflow\nobstruction. Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are mildly thickened (?#). There is mild aortic\nvalve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. The estimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Mild symmetric LVH with small LV cavity size and near-hyperdynamic\nsystolic function. Diastolic dysfunction. A regional wall motion abnormality\ncannot be excluded. Thickened aortic leaflets (?number) with mild aortic\nstenosis.\n\n\n" }, { "category": "ECG", "chartdate": "2196-01-09 00:00:00.000", "description": "Report", "row_id": 257887, "text": "Sinus rhythm and occasional atrial ectopy. The tracing is marred by baseline\nartifact. There is low precordial lead voltage and delayed precordial R wave\ntransition. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2118-02-11 00:00:00.000", "description": "PTA VENOUS", "row_id": 1179772, "text": " 3:56 PM\n AV FISTULOGRAM SCH Clip # \n Reason: Please evaluate for downstream obstruction.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 139\n ********************************* CPT Codes ********************************\n * PTA VENOUS INTRO DIALYSIS FISTULA *\n * -51 MULTI-PROCEDURE SAME DAY PTA VENOUS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ESRD and fisutula with high recirculation rate.\n REASON FOR THIS EXAMINATION:\n Please evaluate for downstream obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n AV FISTULOGRAM WITH VENOPLASTY\n\n MEDICAL HISTORY: 67-year-old man with end-stage renal disease and fistula\n with high recirculation rate. Please evaluate for downstream obstruction.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n 25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intraservice\n time of 1 hour and 5 minutes during which the patient's hemodynamic parameters\n were continuously monitored. 1 % lidocaine was used for local pain control.\n\n OPERATORS: Dr. (fellow) and Dr. (attending\n interventional radiologist) was present and supervising throughout the entire\n procedure.\n\n PROCEDURE AND FINDINGS: After explanation of the procedure and discussion of\n the risks, benefits and alternatives to the procedure with the patient via a\n Korean translator, written informed consent was obtained. The patient was\n brought to the angiography suite and placed supine on the imaging table. The\n patient's left arm was prepped and draped in the usual sterile fashion. A\n preprocedure timeout and huddle were performed per protocol.\n\n Using 1% lidocaine for local pain control, a 21-gauge micropuncture needle was\n used to gain access at the AV fistula on the venous side of the arterial\n anastomosis. A 0.018 micropuncture wire was advanced into the fistula under\n fluoroscopic guidance. The needle was exchanged for a 4.5 French\n micropuncture sheath. Venograms of the AV fistula (both venous and arterial),\n left upper extremity, subclavian and central veins were performed. There was\n moderate stenosis of the AV fistula vein in the upper proximal arm and\n distally closer to the to the venous anastomosis. A 0.035 wire was\n advanced and a 7-French long vascular sheath exchanged after dilatation with a\n 5-French dilator. A short 5-French Kumpe catheter was next advanced over a\n 0.035 Glidewire so that the Glidewire was in the subclavian vein. The\n Glidewire was exchanged for a 0.035 straight Amplatz wire. The Kumpe catheter\n was removed.\n\n Over the Amplatz wire, the moderate stenosis at the more upstream portion of\n the AV fistula was dilated using a 12-mm balloon at various pressures. Next\n (Over)\n\n 3:56 PM\n AV FISTULOGRAM SCH Clip # \n Reason: Please evaluate for downstream obstruction.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 139\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the milder stenosis closer to the venous anastomosis was addressed with a\n 12-mm x 4 cm balloon. There was a good angiographic result.\n\n The arterial end of the AV fistula was examined in various projections after\n inflating the blood pressure cuff. No significant stenoses were observed.\n\n All catheters, sheaths and wires were removed. Hemostasis was achieved with\n manual compression and a pursestring suture with 0 silk. Sterile dressings\n were applied. The patient tolerated the procedure well and there were no\n immediate post-procedure complications.\n\n IMPRESSION:\n 1. Successful balloon dilatation of a moderate stenosis upstream from the\n venous anastomosis of the AV fistula in the upper extremity and one more\n proximal to the venous anastomosis using a 12 mm x 4 cm balloon.\n 2. Post-venoplasty venograms demonstrated improved appearance.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179632, "text": " 8:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for free air under the diaphragm.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p EGD which demonstrated bleed a sphincterotomy site\n which was cauterized. Pt now with severe abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please assess for free air under the diaphragm.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:38 P.M. :\n\n HISTORY: 67-year-old man after an EGD to cauterize a sphincterotomy site.\n Now has severe abdominal pain. Look for free air below the diaphragm.\n\n IMPRESSION: AP chest compared to :\n\n There is no free subdiaphragmatic gas on the left side. There may be a sliver\n of subdiaphragmatic gas on the right. There is an unusual gas collection in\n the right upper abdominal quadrant which could be dilated bowel wall,\n particularly transverse colon, but I would recommend additional imaging\n including decubitus and overhead views to re-evaluate this area. The lungs\n are clear. Mediastinum normal and there is no pleural abnormality. Right\n atrial and right ventricular pacer leads are in their expected locations.\n\n Dr. and I discussed the findings and their clinical significance\n over the telephone at the time of dictation..\n\n" }, { "category": "Radiology", "chartdate": "2118-02-12 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1179824, "text": " 4:02 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pls eval for perf.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with melena after ERCP on , perf.\n REASON FOR THIS EXAMINATION:\n pls eval for perf.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg SAT 5:02 AM\n No free air\n Gas within CBD and GB recent ERCP\n No acute intrabdominal findings\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 67-year-old male with two recent ERCPs. Question free\n air.\n\n COMPARISON: Portable chest , KUB .\n\n TECHNIQUE: Multiple contiguous axial images from the lung bases to the greater\n trochanters were obtained with IV contrast. Coronal and sagittal reformatted\n images were obtained as well.\n\n FINDINGS:\n\n LUNG BASES: There is no pericardial effusion. Pacemaker leads are\n incidentally noted. There is minimal right pleural effusion.\n\n ABDOMEN: Gas within the common bile duct, anterior biliary tree, and\n gallbladder consistent with recent ERCP procedure.\n\n There is no extraluminal or retroperitoneal gas or fluid collection to suggest\n perforation. With the exception of the above, the pancreas and liver are\n normal in appearance. There is some inflammatory wall thickening of the\n gallbladder. The spleen is unremarkable. The kidneys are atrophic\n bilaterally and contain numerous hypodensities, some of which are cysts and\n some of which are too small to characterize. The adrenals are normal\n bilaterally.\n\n The stomach is significant for thickening of the gastric antrum as described\n previously, however this may be due to decompression. Visualized loops of\n small bowel are normal in caliber and enhancement. There is no\n intraperitoneal free air or free fluid. The aorta is mildly calcified and\n normal in caliber along its course, its major branches appear patent. There\n is no retroperitoneal lymphadenopathy.\n\n PELVIS: The rectum contains air-fluid level. The colon is normal in\n appearance along its course. The appendix is normal. The bladder is\n decompressed. The prostate is unremarkable. There is no pelvic side wall\n (Over)\n\n 4:02 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pls eval for perf.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lymphadenopathy.\n\n BONES: No concerning lytic or blastic osseous lesions.\n\n IMPRESSION:\n\n 1. No free air or perforation.\n\n 2. Pneumobilia, post-ercp.\n\n Findings were discussed with Dr. , of surgery.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-10 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1179633, "text": " 8:57 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for SBO vs perforated viscus or other signs of\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p EGD which demonstrated bleed a sphincterotomy site\n which was cauterized. Pt now with severe abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please assess for SBO vs perforated viscus or other signs of acute abdominal\n pain.\n ______________________________________________________________________________\n WET READ: NATg FRI 12:24 AM\n No free air. Normal abdominal bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe abdominal pain after EGD. Evaluate for SBO versus\n perforated viscus.\n\n FINDINGS: A single supine abdominal radiograph was obtained. Air fills\n non-dilated loops of small and large bowel all the way to the right colon. No\n signs of obstruction are visible. No signs of free peritoneal air, but no\n upright film was obtained. Osseous structures are grossly unremarkable.\n\n IMPRESSION: Non-obstructive bowel gas pattern. No evidence of free air. An\n upright radiograph would be more sensitive if clinical concern persists.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2184-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959287, "text": " 5:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess placement of ETT and OG tube\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, with hypoventilation s/p intubation\n\n REASON FOR THIS EXAMINATION:\n Please assess placement of ETT and OG tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP.\n\n HISTORY: 40-year-old woman with severe obstructive sleep apnea,\n hypoventilation status post intubation. Assess endotracheal and orogastric\n tubes.\n\n FINDINGS: AP supine portable radiograph, comparison , demonstrates\n interval placement of an endotracheal tube which terminates 4.5 cm above the\n carina. The orogastric tube tip is outside the field of view but tubing\n passes below the left hemidiaphragm. Moderate-to-severe cardiomegaly is not\n significantly changed. A small right pleural effusion blunts the costophrenic\n sulcus.\n\n Left retrocardiac opacity is slightly increased since prior study, atelectasis\n versus pneumonia.\n\n IMPRESSION: Adequate support apparatus placement.\n\n Retrocardiac opacity, might be better evaluated with PA and lateral\n radiographs.\n\n Small right pleural effusion.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2184-05-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 958929, "text": " 7:37 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 YO F with SOB and CP\n REASON FOR THIS EXAMINATION:\n assess for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray, PA and lateral views.\n\n INDICATION: 40-year-old female with shortness of breath and chest pain.\n Assess for acute cardiopulmonary process.\n\n COMPARISON: .\n\n FINDINGS: Severe cardiomegaly is unchanged compared to the previous\n examination. There is prominence of the upper zone pulmonary vasculature\n consistent with redistribution. There is a small to moderate right-sided\n pleural effusion. There is no left pleural effusion. No focal opacities are\n identified.\n\n IMPRESSION: Findings consistent with congestive heart failure. Small-to-\n moderate right-sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2184-05-23 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 958930, "text": " 7:47 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: assess for PE, acute cardiopulmonary process\n Admitting Diagnosis: CHEST PAIN\n Field of view: 31 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 YO F with CHF, AFib p/w SOB and CP\n REASON FOR THIS EXAMINATION:\n assess for PE, acute cardiopulmonary process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb SUN 10:34 PM\n no pe. there is enlarged small/moderate right effusion with right lower\n infiltrate. more likely atelectasis but pneumonia is consideration given\n appearance. cardiomegaly is stable.\n WET READ VERSION #1 AHPb SUN 8:24 PM\n no pe. there is enlarged small/moderate right effusion with right lower\n infiltrate. more likely atelectasis but pneumonia is consideration given\n appearance. cardiomegaly is stable.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, AFib, with shortness of breath and chest pain. Evaluate for\n PE.\n\n COMPARISON: .\n\n TECHNIQUE: Contrast-enhanced axial CT imaging of the chest was performed\n after the uneventful administration of 90 cc Optiray contrast. Multiplanar\n reformatted images were also obtained.\n\n CT CHEST WITH CONTRAST: The pulmonary arteries opacify without filling\n defects. Marked multi-chamber cardiomegaly is stable. There is no pathologic\n adenopathy. Small right pleural effusion has enlarged from the prior.\n Associated right lower lobe consolidation is likely atelectasis, but\n infiltrate is not entirely excluded. Mosaic ground glass in the left base is\n secondary to hypoventilation. The visualized abdomen is remarkable for\n hepatic reflux of contrast.\n\n BONE WINDOWS: No suspicious osseous lesions are identified.\n\n IMPRESSION:\n 1. Enlarging small right pleural effusion with right lower lobe atelectasis\n versus infiltrate.\n 2. Stable marked cardiomegaly.\n 3. No pulmonary embolus.\n\n" }, { "category": "Radiology", "chartdate": "2184-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958961, "text": " 8:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion, HF\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n eval for effusion, HF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP.\n\n HISTORY: 40-year-old woman with worsening hypoxia, evaluate for effusion and\n heart failure.\n\n FINDINGS: Single upright portable AP of chest, comparison ,\n demonstrates stable moderate-to-severe cardiomegaly. The small-to-moderate\n right pleural effusion has increased slightly since prior study. Cephalization\n and vascular prominence are evident.\n\n IMPRESSION:\n\n 1. Small-to-moderate right pleural effusion.\n 2. Moderate-to-severe cardiomegaly.\n 3. Mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2184-05-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 959418, "text": " 8:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval lines, tubes, infiltrates\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, with hypoventilation s/p intubation now\n with new left subclavian line\n REASON FOR THIS EXAMINATION:\n eval lines, tubes, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST RADIOGRAPH\n\n INDICATION: 40-year-old woman status post intubation and new left subclavian\n line.\n\n COMPARISON: .\n\n FINDINGS: Patient is status post intubation with ET tube terminating 4.4 cm\n above the carina. There has been interval placement of left subclavian access\n central venous catheter terminating in the expected location of the proximal\n SVC. The nasogastric tube side ports are projecting below the expected\n location of the GE junction.\n\n There is persistent cardiomegaly. There are bilateral pleural effusions, as\n well as cephalization and indistinctness of pulmonary vasculature, consistent\n with volume overload. Left retrocardiac opacity has not significantly changed\n from previous examination and may represent atelectasis versus an infiltrate.\n\n IMPRESSION:\n 1. Findings consistent with volume overload.\n 2. Left retrocardiac opacity may represent atelectasis versus an infiltrate.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2184-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959478, "text": " 9:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines, tubes inifiltrates\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, with hypoventilation s/p intubation with\n notable Hct decrease following subclavian line placement\n REASON FOR THIS EXAMINATION:\n eval lines, tubes inifiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Severe OSA, with hypoventilation, status post intubation with\n notable hematocrit decrease following subclavian line placement.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-erect\n position is analyzed in direct comparison with a similar preceding study dated\n . Cardiomegaly persists. The patient remains intubated, the ETT\n in unchanged position. The same holds for the previously-described left\n subclavian central venous line. There is no pneumothorax. Basal densities\n most likely representing pleural effusions have further increased.\n Retrocardiac density persists and lung bases cannot be evaluated in detail.\n\n IMPRESSION: Increasing pleural densities in a patient with marked\n cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961098, "text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines, tubes, infiltrates\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation getting diuresis\n\n REASON FOR THIS EXAMINATION:\n eval lines, tubes, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old female with severe obstructive sleep apnea. Interval\n change.\n\n Comparison is made to prior radiographs dated and .\n\n SUPINE PORTABLE CHEST RADIOGRAPH:\n\n FINDINGS: There is improved aeration of both lower lobes bilaterally with\n stable appearance to bilateral pleural effusions, retrocardiac opacity, and\n right basilar atelectasis. Vascular engorgement persists without evidence of\n frank interstitial pulmonary edema. Cardiac silhouette remains enlarged and a\n left-sided central venous catheter and orogastric tube remain in standard\n position. Tip of endotracheal tube terminates approximately 2 cm in the\n carina.\n\n IMPRESSION:\n Decreased lower lobe atelectasis bilaterally with persistent bilateral pleural\n effusions (right greater than left).\n\n" }, { "category": "Radiology", "chartdate": "2184-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959130, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with worsening hypoxia.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST 7:52 A.M.\n\n INDICATION: Worsening hypoxia.\n\n FINDINGS: Compared with 4/30, no obvious interval change, allowing for\n underpenetration due to overlying soft tissues. The right pleural effusion,\n better seen on the patient's recent CT, appears grossly unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-11 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 961621, "text": " 8:22 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Evaluate for DVTs.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with persistent fevers despite antibiotics, obesity.\n REASON FOR THIS EXAMINATION:\n Evaluate for DVTs.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman with persistent fevers despite antibiotics,\n obesity, evaluate for DVT.\n\n TECHNIQUE: Using scale with compression, color and spectral Doppler the\n study was performed.\n\n RIGHT LOWER EXTREMITY: There is no son evidence of deep venous\n thrombosis in the femoral, popliteal and calf vessels of the right lower\n extremity.\n\n LEFT LOWER EXTREMITY: There is no evidence for deep venous thrombosis of the\n femoral, popliteal and calf vessels of the left lower extremity. No fluid\n collections are seen.\n\n IMPRESSION: No son evidence for deep venous thrombosis in bilateral\n lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960853, "text": " 3:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess tube placement.\n\n Single portable radiograph of the chest demonstrates no change in the\n cardiomediastinal contours when compared to . Bilateral pleural\n effusions and bibasilar atelectasis persist. Mild increased airspace opacity\n is seen to involve both lungs. Diagnostic quality is slightly limited by\n technique. The trachea is midline. No pneumothorax. Support lines are\n unchanged.\n\n IMPRESSION:\n Persistent bilateral pleural effusions and bibasilar atelectasis.\n\n Increased airspace opacity involving both lungs. Diagnostic considerations\n include pulmonary edema. Finding is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960269, "text": " 4:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval cardiopulm status\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation now on lasix gtt\n\n REASON FOR THIS EXAMINATION:\n pls eval cardiopulm status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe obstructive sleep apnea, status post intubation, now on\n Lasix.\n\n COMPARISON: Prior chest radiograph from a portable chest radiograph from and .\n\n TECHNIQUE AND FINDINGS: A portable chest radiograph was obtained in frontal\n projection and supine position.\n\n The patient is slightly rotated to the left as compared to the 2 prior\n examinations. Also, the film is markedly underpenetrated and suboptimal in\n quality. In these conditions, no major change is noticeable, but repeat chest\n radiograph with improved technique is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960613, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for any interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation\n REASON FOR THIS EXAMINATION:\n assess for any interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with severe OSA status post intubation.\n\n COMPARISON: Studies from .\n\n AP SUPINE CHEST: Endotracheal tube remains close to the carina, 2.4 cm above\n it. Nasogastric tube tip extends below the film. A left subclavian central\n venous catheter tip extends to the junction of the SVC and brachiocephalic\n vein. Large cardiac size is unchanged. Opacity in the retrocardiac left\n lower lobe as well as mild pulmonary vascular congestion persist, the latter\n appears more prominent than on the prior study, with worsened left\n cephalization.\n\n IMPRESSION:\n 1. Endotracheal tube adequately positioned above carina.\n 2. Mild pulmonary vascular congestion is worsened particularly on the left.\n Cardiomegaly and retrocardiac left lower lobe opacity which may represent\n atelectasis are stable.\n\n" }, { "category": "Radiology", "chartdate": "2184-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959604, "text": " 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, with hypoventilation s/p intubation with\n notable Hct decrease following subclavian line placement\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old female with severe obstructive sleep apnea status post\n intubation. Evaluate for interval change.\n\n Comparison is made to prior chest radiographs dating back to \n and CTA chest dated .\n\n PORTABLE SUPINE CHEST RADIOGRAPH.\n\n FINDINGS:\n There is a persistent hazy opacity projecting over the right mid and lower\n hemithorax with blunting of the costophrenic angle and obscuration of the\n hemidiaphragm consistent with layering pleural effusion and underlying\n atelectasis. Small left-sided pleural effusion is also present with unchanged\n appearance to retrocardiac density ( atelectasis versus consolidation). There\n is no evidence of new infiltrates, pneumothorax, or pulmonary edema. Heart\n size remains enlarged and is unchanged positioning to endotracheal tube and a\n left-sided CVL. The superior mediastinum does not appear particularly widened\n to suggest underlying hematoma when compared to pre-line placement radiographs\n with same supine portable technique dated .\n\n IMPRESSION: Grossly stable appearance to bilateral pleural effusions and\n probable underlying atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960757, "text": " 3:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for effusion, cardiopulm process\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation, patient expelled OG tube,\n replaced\n REASON FOR THIS EXAMINATION:\n pls eval for effusion, cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient expelled OG tube, which has been replaced.\n\n Single AP view of the chest is obtained at 0400 hours and is compared\n with the most recent study performed at 2100 hours. There is an\n orogastric tube with its tip below the diaphragm but not included on the\n current image. It appears to be at least in the gastric body. The remainder\n of the tubes and lines are unchanged in position. Again is seen increased\n density at both bases consistent with pleural fluid together with likely air\n space disease/atelectasis at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960943, "text": " 3:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Intubation.\n\n Endotracheal tube has been repositioned, now terminating about 4.5 cm above\n the carina with the neck apparently in a flexed position. Nasogastric tube\n courses below the diaphragm but side port could potentially be above the GE\n junction level. Cardiac silhouette is enlarged but stable in size. Vascular\n engorgement and perihilar haziness shows slight improvement suggesting\n improving volume status with decreasing pulmonary edema. Moderate right\n pleural effusion is slightly smaller, and small left pleural effusion is\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961555, "text": " 5:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for trach placement / etc\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe resp failure now s/p trach and peg\n REASON FOR THIS EXAMINATION:\n please assess for trach placement / etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe respiratory failure status post trach and PEG. Assess for\n trach placement.\n\n COMPARISON: Chest x-ray from 14 hours prior.\n\n SINGLE AP SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPH: There has been interval\n placement of a tracheostomy tube with tip approximately 5.6 cm above the\n carina. Right subclavian line terminates at the mid SVC. There is no\n pneumothorax. There has been slight decrease to small bilateral pleural\n effusions and pulmonary edema with some residual cephalization and\n perivascular haziness. Retrocardiac opacity with clustered bronchial markings\n is likely due to atelectasis.\n\n IMPRESSION: Interval placement of tracheostomy tube, in satisfactory\n position. Mild improvement in CHF. Left basilar atelectasis persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-03 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 960592, "text": " 8:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please check placement of OG tube\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation, patient expelled OG tube,\n replaced\n REASON FOR THIS EXAMINATION:\n please check placement of OG tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with severe OSA, OG tube replaced.\n\n COMPARISON: 4:54 a.m. the same day.\n\n AP SUPINE CHEST: Orogastric tube extends below the hemidiaphragms.\n Cardiomegaly is stable. Pulmonary vascular congestion is worsened although\n the lungs appear better expanded than on the prior study. Endotracheal tube\n is roughly 2.6 cm above the carina. A poorly defined retrocardiac opacity\n persists and there is a small right-sided pleural effusion.\n\n IMPRESSION: Appropriately placed nasogastric tube. Worsened pulmonary\n congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960769, "text": " 5:29 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT position\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation, now s/p self extubation\n (partial - tube re-inserted).\n REASON FOR THIS EXAMINATION:\n eval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: One view chest, .\n\n COMPARISON: One view chest and .\n\n INDICATION: Status post self extubation with partial tube reinsertion,\n evaluate ET tube position.\n\n FINDINGS: Single frontal radiograph of the chest demonstrates unchanged\n position of the left subclavian central line, NG tube, distal tip excluded by\n columnation. An endotracheal tube is seen overlying the tracheal air column\n distal tip at the level of the carina, recommend withdrawing approximately 3\n cm. The cardiac silhouette is enlarged, unchanged. Again seen are bilateral\n pleural effusions and pulmonary edema, unchanged. There is no evidence of\n pneumothorax. There is retrocardiac airspace opacity, likely atelectasis.\n\n IMPRESSION:\n\n 1. Unchanged appearance of the lungs.\n\n 2. Low position of the endotracheal tube, recommend withdrawing approximately\n 3 cm. Findings discussed with the nurse taking care of the patient on .\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960110, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check placement of OG and ETT as OG tube replaced\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation now on lasix gtt\n\n REASON FOR THIS EXAMINATION:\n check placement of OG and ETT as OG tube replaced\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:05 a.m., .\n\n HISTORY: Intubated. On diuresis.\n\n IMPRESSION: AP chest compared to through :\n\n Mild pulmonary edema, particularly in the left upper lung has worsened\n slightly since . Severe cardiomegaly is longstanding. Small right\n pleural effusion has increased. Tip of the ET tube could be as close as 1.5\n cm to the carina but this position is acceptable with the neck flexed.\n Nasogastric tube passes into the stomach and out of view. Left subclavian\n line tip projects over the left brachiocephalic vein.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961440, "text": " 3:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, intubated\n REASON FOR THIS EXAMINATION:\n compare\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient intubated with severe OFA.\n\n COMPARISON: .\n\n The right subclavian line tip terminates in the superior vena cava. There is\n no pneumothorax, apical hematoma or increased pleural effusion. The NG tube\n tip passes below the diaphragm, most likely terminating in the stomach. The\n ET tube tip is 5 cm above the carina. The bibasal atelectasis is grossly\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-05-31 00:00:00.000", "description": "CT SINUS W/ CONTRAST", "row_id": 960045, "text": " 5:11 PM\n CT SINUS W/ CONTRAST Clip # \n Reason: eval for sinusitis and peritonsilar abscess\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with fusobacterium bacteremia concern for sinusitis and\n peritonsilar abscess\n REASON FOR THIS EXAMINATION:\n eval for sinusitis and peritonsilar abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 40-year-old woman with fusobacterium bacteremia. Concern for\n sinusitis or peritonsillar abscess.\n\n TECHNIQUE: Axial CT images of the paranasal sinuses were obtained with\n intravenous contrast and coronal reconstructions were also performed.\n\n FINDINGS: There are air-fluid levels in the sphenoid and maxillary sinuses,\n with complete opacification of the right sphenoid sinus. There is also fluid\n in the nasal cavity and near-opacification of the ethmoid cells bilaterally\n with a small air-fluid level in the left frontal sinus. There is no evidence\n of associated bony destruction.\n\n The fluid and soft tissue thickening among the paranasal sinuses is of\n intermediate density. The patient is intubated with an orogastric tube. The\n orbits are within normal limits. There are bilateral small areas of relative\n hypodensity in the nasopharyngeal soft tissues but without well- defined fluid\n collections.\n\n There is a defect in the right orbital floor, presumably due to an old\n inferior blow out fracture.\n\n IMPRESSION: Although endotracheal intubation confounds interpretation,\n extensive opacification with multiple air-fluid levels among the paranasal\n sinuses can be seen in pansinusitis. No evidence of associated bony\n destruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-05-31 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 960046, "text": " 5:11 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval sinusitis or peritonsilar abscess\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with fusobacterium bacteremia concern for sinusitis and\n peritonsilar abscess\n REASON FOR THIS EXAMINATION:\n eval sinusitis or peritonsilar abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 40-year-old woman with fusobacterium bacteremia. Concern for\n sinusitis or peritonsillar abscess. Status post intubation.\n\n COMPARISONS: .\n\n TECHNIQUE: Axial CT images of the neck were obtained with intravenous\n contrast.\n\n FINDINGS: The patient is intubated, and an orogastric tube courses into the\n visualized esophagus. There is marked circumferential soft tissue thickening\n in the oropharynx, extending into the nasopharynx but with no evidence of\n well-defined fluid collection.\n\n There are mildly enlarged bilateral parapharyngeal lymph nodes. The\n hypopharynx is also effaced, with circumferential soft tissue. The\n supraglottic region is also involved with marked soft tissue thickening which\n also extends partly into the infraglottic airway. More inferiorly, the\n visualized trachea appears patent, and the upper mediastinum is unremarkable.\n\n There is inflammatory change in the anterior subcutaneous fat with multiple\n lymph nodes, anterior to a site of prior inflammation that was suspected to\n relate to a thyroglossal duct cyst. As before, soft tissue about this area is\n contiguous with the anterior thyroid, but the thyroid otherwise appears\n normal. The major arteries and veins of the neck appear patent. The parotid\n and submandibular glands are unremarkable. There are multiple bilateral\n mildly prominent cervical lymph nodes.\n\n There is near-opacification of the paranasal sinuses, better described on a\n sinus CT of the same day. Air-fluid levels in the sphenoid and maxillary\n sinuses, as well as fluid in the nasal cavity and soft tissue thickening in\n the nasopharynx.\n\n Although noisy images somewhat compromise evaluation, there is no definite\n evidence of prevertebral extension of inflammation.\n\n There are bilateral pleural effusions. The lung apices are clear. The\n osseous structures are unremarkable.\n\n IMPRESSION:\n (Over)\n\n 5:11 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval sinusitis or peritonsilar abscess\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Soft tissue stranding and lymphadenopathy in the tissues anterior and\n contiguous with the thyroid, which is similar to what was seen in , but\n again suggesting acute inflammation.\n\n 2. Marked soft tissue swelling involving the entire pharynx, as well as the\n supraglottic and the upper infraglottic airway.\n\n 2. No organized fluid collection identified or bony involvement.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961734, "text": " 3:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe resp failure now s/p trach and peg\n\n REASON FOR THIS EXAMINATION:\n compare\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post pericardial window.\n\n COMPARISON: at 1818\n\n PORTABLE CHEST RADIOGRAPH: Right subclavian line tip is in the mid SVC\n unchanged. There is no pneumothorax. Tracheostomy tube tip is in stable\n position. Small bilateral pleural effusions are unchanged. The\n cardiomediastinal silhouette is unchanged. Mild-to-moderate degree of\n pulmonary edema is unchanged. Left basilar atelectasis/consolidation is\n unchanged.\n\n IMPRESSION: Unchanged confluent edema, underlying infection cannot be\n excluded. Repeat chest radiograph after diuresis should be considered.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961250, "text": " 9:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ETT placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p self-extubation and re-intubation\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST, 9:33 P.M., \n\n INDICATION: ETT placement status post reintubation.\n\n FINDINGS: Compared with the study earlier the same day at 4:05 a.m., the tip\n of the current ETT projects approximately 4 cm above the carina.\n\n No other obvious significant changes, allowing for technique. Persistent\n bibasilar atelectasis/infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959919, "text": " 3:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please re-evaluate fluid balance.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation now on lasix gtt\n\n REASON FOR THIS EXAMINATION:\n Please re-evaluate fluid balance.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:06 A.M. \n\n HISTORY: Intubated. Evaluate fluid balance.\n\n IMPRESSION: AP chest compared to through 6:\n\n Severe cardiomegaly is longstanding. Moderate pulmonary edema and small right\n pleural effusion are unchanged since . Tip of the ET tube 3 cm from the\n carina is in standard placement. Left subclavian line ends in the upper SVC\n and nasogastric tube passes below the diaphragm and out of view. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962080, "text": " 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evalf or effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe resp failure now s/p trach and peg, pulled out\n her trach, now replaced.\n REASON FOR THIS EXAMINATION:\n evalf or effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:09 A.M., .\n\n HISTORY: Severe respiratory failure. Tracheostomy tube.\n\n IMPRESSION: AP chest compared to through 20:\n\n Severe cardiomegaly has worsened since . Marked pulmonary vascular\n engorgement and mild edema have worsened since . More focal\n opacification at the right lung base is stable and could be pneumonia or\n atelectasis. Pleural effusion if any is small, on the right. Tracheostomy\n tube in standard placement. Right subclavian line tip projects over the mid\n to lower SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960779, "text": " 7:16 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for ETT position\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation, now s/p self extubation,\n tube repositioned\n REASON FOR THIS EXAMINATION:\n please eval for ETT position\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Re-positioning of ET tube.\n\n A single AP view of the chest is obtained at 0815 hours following\n reposition of an ET tube. The tip of the tube is still only 1.5 cm from the\n carina and could be further repositioned. The remainder of the examination is\n unchanged with a hazy opacity at both bases consistent with pleural fluid\n together with increased retrocardiac density on the left side consistent with\n airspace disease/atelectasis superimposed.\n\n Dr. was paged and the findings were discussed.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960446, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INTERVAL CHANGE\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess for interval change.\n\n Comparison is made to prior chest radiographs dated and and\n prior CT dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH.\n\n FINDINGS:\n\n There has been improved aeration of the right and left lower lobes with\n decreased interstitial pulmonary edema. Mild opacity projecting over the\n right mid and lower lung fields may represent a layering pleural effusion on\n this supine film. There is persistent retrocardiac opacity. Endotracheal\n tube tip is approximately 1.6 cm from the carina and nasogastric tube\n terminates beneath the diaphragm.\n\n IMPRESSION:\n\n 1. Improved aeration of right and left lower lobes with persistent\n retrocardiac opacity representing atelectasis or consolidation.\n\n 2. Improved interstitial edema.\n\n 3. Stable position to left-sided central venous catheter with endotracheal\n tube approximately 1.6 cm from the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959838, "text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation now on lasix gtt\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Interval change. Intubated.\n\n Lines and tubes are unchanged in position. Cardiac silhouette remains\n markedly enlarged with associated widening of the vascular pedicle. Vascular\n engorgement and perihilar haziness, likely due to pulmonary edema from fluid\n overload are not substantially changed, with persistent pleural effusions,\n right greater than left.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961908, "text": " 4:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please re-evaluate lung fields post-reinserting trach.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe resp failure now s/p trach and peg, pulled out\n her trach, now replaced.\n REASON FOR THIS EXAMINATION:\n Please re-evaluate lung fields post-reinserting trach.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , AT 16:52 HOURS.\n\n HISTORY: Severe respiratory failure post re-inserting tracheostomy tube.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Slight interval decrease in vascular congestion and upper lobe\n cephalization. There are persistent bibasilar opacities with air\n bronchograms. The small right pleural effusion is relatively stable. Support\n tubes and lines are unchanged. The cardiac silhouette size remains enlarged\n but stable.\n\n IMPRESSION: Cardiogenic pulmonary edema persists. Bibasilar opacities with\n air bronchograms remain evident and may represent multifocal pneumonia versus\n confluent edema. Repeat radiography following appropriate diuresis\n recommended to assess for underlying infection. There is a small right\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 961377, "text": " 3:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please assess line placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, with new R subclavian line placed\n REASON FOR THIS EXAMINATION:\n please assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of right subclavian line placement.\n\n Portable AP chest radiograph compared to .\n\n The right subclavian line tip terminates in the distal brachiocephalic vein.\n There is no pneumothorax, apical hematoma, or increased pleural effusion. The\n ET tube and the NG tube are in unchanged position.\n\n The bibasilar atelectasis has slightly improved.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-10 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 961552, "text": " 5:10 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval for sinusitis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman w/ obesity hypoven on chronic vent with persistent fever\n REASON FOR THIS EXAMINATION:\n eval for sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Obesity and hypoventilation, on chronic vent, with persistent\n fever. Evaluate for sinusitis.\n\n COMPARISON: .\n\n TECHNIQUE: Continuous helical scanning through the sinuses was performed\n without IV contrast in both soft tissue and bone algorithm and coronal\n reformats were displayed.\n\n CT OF THE SINUSES: Compared to 10 days prior, there has been improvement in\n extensive sinus opacification. Previously seen air-fluid levels in the\n maxillary and sphenoid sinuses have resolved with mild residual mucosal\n thickening in the maxillary sinuses. Moderate ethmoid sinus opacification\n persists as well as near complete opacification of the sphenoid sinus. The\n frontal sinuses are clear. Mastoid air cells continue to be nearly completely\n opacified. The orbits are within normal limits. There is no evidence of\n associated bony destruction.\n\n IMPRESSION: Improvement in pansinusitis with residual opacification of the\n sphenoid and ethmoid sinuses, as well as the mastoid air cells. Minimal\n mucosal thickening remains in the maxillary sinuses.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960745, "text": " 8:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Pelase evaluate tube positioning\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe OSA, s/p intubation, now s/p self extubation\n (partial - tube re-inserted).\n REASON FOR THIS EXAMINATION:\n Pelase evaluate tube positioning\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST SEMI-ERECT, , 2100 HOURS.\n\n Single AP view of the chest was obtained and is compared with the most recent\n study performed at 0530 hours the same day. The patient remains intubated\n with the tip of the ET tube approximately 2.5 cm above the carina. There is\n diffuse cardiomegaly. There are bilateral pleural effusions. Loss of the\n left hemidiaphragm shadow is consistent with the fluid together with airspace\n disease/atelectasis at the left base. A left-sided subclavian line has its\n tip near the junction of the brachiocephalic and SVC. An orogastric tube is\n present with its tip below the diaphragm but not included on the current\n examination.\n\n IMPRESSION:\n\n Bilateral pleural effusions, which appear to have increased since the prior\n examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962228, "text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe resp failure now s/p trach and peg, pulled\n out her trach, now replaced.\n REASON FOR THIS EXAMINATION:\n compare\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy replacement.\n\n CHEST, ONE VIEW: Comparison with , 5:09 a.m. Cardiomegaly.\n Improved appearance of lung fields. Residual small pleural effusion on the\n right. Retrocardiac atelectasis. Mild residual pulmonary edema probably\n present. Tracheostomy tube in good position, approximately 4 cm above the\n carina. Right subclavian line unchanged.\n\n IMPRESSION: Improved appearance of both lung fields. Mild cardiac failure\n and small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-16 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 962368, "text": " 5:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for underlying infectious process\n Admitting Diagnosis: CHEST PAIN\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with CHF, resp failure, s/p trach/peg, with persistent fever\n no clear source\n REASON FOR THIS EXAMINATION:\n assess for underlying infectious process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF and respiratory failure, status post trach and PEG with\n persistent fevers and no clear source. Evaluate for underlying infectious\n process.\n\n COMPARISON: CTA chest, and .\n\n TECHNIQUE: Multidetector helical scanning of the chest, abdomen and pelvis\n were performed with oral and IV contrast. Coronal and sagittal reformats were\n displayed.\n\n CT OF THE CHEST: Tracheostomy tube is in place with mild stranding of the\n anterior neck subcutaneous tissues. No abscess is identified in this region.\n Subcentimeter mediastinal lymph nodes are noted, none of which meet CT\n criteria for pathologic enlargement. The heart is severely enlarged,\n unchanged compared to . The pericardium and great vessels are\n unremarkable. The bronchi are patent to the subsegmental level. Respiratory\n motion degrades full evaluation of the lung parenchyma, however there are\n scattered areas of ground-glass opacity in both lobes suggestive of mild\n pulmonary edema. In addition, there is a heterogeneously enhancing airspace\n opacity at the left lung base with air bronchograms, consistent with\n pneumonia. Tiny bilateral pleural effusions exist, right greater than left,\n with associated relaxation atelectasis at the right lung base.\n\n CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: A 1.2 x 1.4 cm hyperattenuating\n right adrenal nodule does not meet CT criteria for an adrenal adenoma\n (measures 98 Hounsfield units) and cannot be further characterized on this\n contrast-enhanced CT. There is thickening with a possible nodule in the medial\n limb of the left adrenal gland. The liver, gallbladder, spleen, pancreas and\n kidneys are unremarkable. No ascites, mesenteric lymphadenopathy or bowel\n obstruction. A number of retroperitoneal lymph nodes measuring up to 7 mm in\n short axis are noted. A PEG tube is seen terminating within the stomach.\n\n CT OF THE PELVIS WITH ORAL AND IV CONTRAST: Foley catheter is seen within the\n bladder. The sigmoid colon and rectum are filled with fluid and stool. The\n uterus and adnexa are unremarkable. No free fluid or pelvic lymphadenopathy.\n\n No suspicious lytic or sclerotic lesions. Prominent anterior osteophytes are\n seen at T8-9.\n (Over)\n\n 5:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for underlying infectious process\n Admitting Diagnosis: CHEST PAIN\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Within the soft tissues, there is fluid and stranding in the left flank,\n likely related to patient immobility and positioning. Numerous soft tissue\n opacities are seen in the anterior right and left mid abdomen, presumably\n injection granulomas.\n\n IMPRESSION:\n 1. Left lower lobe pneumonia.\n 2. Right adrenal nodule and possible left adrenal nodule, both\n hyperattenuating and cannot be further characterized by this contrast-enhanced\n scan. IF clinically indicated, a non-contrast CT or MRI could provide\n further characterization of these lesions.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962617, "text": " 10:44 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: trach placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40f with resp failure, trached, trached pulled out, now replaced\n REASON FOR THIS EXAMINATION:\n trach placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Replacement of ET tube.\n\n A single image of the chest is obtained on at 1100 hours to reassess\n ET tube position after it had been pulled out. The lower portion of the chest\n is not included on the current image. The patient has a tracheostomy in\n place, with the tip approximately 5 cm above the carina. Right-sided\n subclavian line is in place with the tip projecting over the expected location\n of the proximal SVC. Since the lower portion of the chest is not included on\n the current images, it is difficult to fully evaluate for pulmonary changes\n since the prior examination, but there does appear to be increased\n retrocardiac density on the left side consistent with airspace\n disease/atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962806, "text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40f with resp failure, trached, with concern for overload\n REASON FOR THIS EXAMINATION:\n eval lung fields\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Respiratory failure.\n\n A single AP view of the chest is obtained at 0415 hours and is\n compared with the prior radiograph performed at 1635 hours. Patient\n remains with a tracheostomy tube which appears to have been repositioned. The\n tip of the tracheostomy tube is approximately 7 cm above the carina. Left-\n sided subclavian line is unchanged in position. Right-sided subclavian line\n has been removed.\n\n Cardiomegaly persists. There is mild pulmonary vascular prominence which is\n more marked than on the prior examination. There may be a small right-sided\n pleural effusion.\n\n IMPRESSION:\n 1. Cardiomegaly with mild pulmonary vascular congestion. No frank pulmonary\n edema.\n 2. Likely small right pleural effusion.\n 3. Tracheostomy tube with tip approximately 7 cm above the carina.\n\n Dr. was paged at hours and the above findings were discussed.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962569, "text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe resp failure now s/p trach and peg, pna\n\n REASON FOR THIS EXAMINATION:\n compare\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe respiratory failure.\n\n CHEST, ONE VIEW: Comparison with multiple prior examinations, the most recent\n being , chest radiograph and CT torso. Moderate-to-marked\n cardiomegaly is unchanged. Mild pulmonary edema is also unchanged. Bilateral\n lower lobe atelectasis is again identified. No pneumothorax is seen. Osseous\n structures remain unchanged. Tracheostomy tube and right subclavian line are\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962671, "text": " 4:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for l subclv placement, ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40f with resp failure, trached, trached pulled out, now replaced\n\n REASON FOR THIS EXAMINATION:\n eval for l subclv placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Repositioning of the tracheostomy tube.\n\n A single AP view of the chest is obtained on at 1635 hours and is\n compared with a prior radiograph performed at 1100 hours. The patient remains\n with a tracheostomy with the tip approximately 5.8 cm above the carina. Right-\n sided subclavian line is unchanged in position. A new left-sided subclavian\n line has been inserted. Its tip projects over the expected junction of the\n brachiocephalic and superior vena cava. There is no evidence of pneumothorax.\n Increased retrocardiac density on the left side likely represents some\n atelectasis/airspace disease at the left base. Pulmonary vascular engorgement\n and mild edema appears to have improved in the interim.\n\n IMPRESSION:\n\n Insertion of new left-sided subclavian line with the tip at the junction of\n the brachiocephalic and superior vena cava. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962827, "text": " 7:51 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval depth of trach placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40f with resp failure, trached, now s/p trach reposition\n REASON FOR THIS EXAMINATION:\n eval depth of trach placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Reposition of tracheostomy.\n\n A single AP view of the chest is obtained at 0800 hours and is compared with\n the prior radiograph performed almost four hours previously and shows slight\n repositioning of the tracheostomy tube but its tip still is 6.7 cm above the\n carina. No other interval change is noted.\n\n IMPRESSION:\n\n Tip of the tracheostomy tube still 6.7 cm above the carina and could be\n advanced 2 to 3 cm.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962833, "text": " 9:50 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for re-positioned trach\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40f with resp failure, trached, now s/p trach reposition\n\n REASON FOR THIS EXAMINATION:\n assess for re-positioned trach\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n INDICATION: Repositioning of tracheostomy.\n\n A single AP view of the chest is obtained at 10:01 hours and is\n compared with the prior radiograph performed approximately two hours prior.\n Preliminary findings are unchanged. The tracheostomy has been repositioned,\n and its tip now lies approximately 4.5 cm above the carina.\n\n IMPRESSION:\n\n Repositioning of tracheostomy tube, now 4.5 cm above carina.\n\n\n\n\n\n" }, { "category": "Echo", "chartdate": "2184-06-15 00:00:00.000", "description": "Report", "row_id": 95606, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function.\nHeight: (in) 61\nWeight (lb): 300\nBSA (m2): 2.25 m2\nBP (mm Hg): 119/71\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 15:33\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. The aortic\nvalve leaflets appear structurally normal with good leaflet excursion. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. Mild\n(1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Mild mitral regurgitation with grossly normal valve morphology.\nPreserved global biventricular systolic function.\nCompared with the prior study (images reviewed) of , the severity of\ntricuspid regurgitation may be lower (technical quality is suboptimal on both\nstudies). The severity of mitral regurgitation is similar. Left ventricular\nsystolic function was likely underestimated on the prior study.\n\n\n" }, { "category": "ECG", "chartdate": "2184-06-01 00:00:00.000", "description": "Report", "row_id": 252388, "text": "Atrial fibrillation\nRight axis deviation - consider right ventricular overload or possible left\nposterior fascicular block\nModest nonspecific low amplitude T wave changes\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2184-05-29 00:00:00.000", "description": "Report", "row_id": 252389, "text": "Atrial fibrillation. Low R waves in leads V2-V4 probably due to right\nventricular hypertrophy. Possible right ventricular hypertrophy. Compared to\nthe previous tracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 252584, "text": "Atrial fibrillation. Long QTc interval. Low R waves in leads V2-V4 probably due\nto right ventricular hypertrophy. Inferior T wave changes are non-specific.\nRepolarization changes may be partly due to rhythm. Compared to the previous\ntracing of ventricular response is slightly increased.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 252585, "text": "Atrial fibrillation with a rapid ventricular response. Right axis deviation.\nlow precordial lead voltage. Borderline low limb lead voltage. These findings\nsuggest pulmonary pathology.\n\n" }, { "category": "ECG", "chartdate": "2184-05-24 00:00:00.000", "description": "Report", "row_id": 252586, "text": "Atrial fibrillation\nLong QTc interval\nMarked right axis deviation\nPossible anterior infarct\nLate R wave progression\nInferior ST-T changes\nLow QRS voltages in precordial leads\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2184-05-23 00:00:00.000", "description": "Report", "row_id": 252587, "text": "Atrial fibrillation with slow ventricular response\nLong QTc interval\nMarked right axis deviation\nLate R wave progression\nPossible anterior infarct - age undetermined or axis related\nInferior/lateral ST-T changes\nLow QRS voltages\nSince previous tracing of , heart rate slower\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2184-06-10 00:00:00.000", "description": "Report", "row_id": 252387, "text": "Atrial fibrillation\nRight axis deviation - consider right ventricular overload or possible Left\nposterior fascicular block\nModest nonspecific low amplitude T wave changes\nSince previous tracing of , no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-31 00:00:00.000", "description": "Report", "row_id": 1472078, "text": "Respiratory Care: Pt remains intubated and on vent. No parameter changes made this shift. Suctioned small amt white secretions. Received MDI's. Unable to obtain morning , pt made no spontaneous respirations.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-31 00:00:00.000", "description": "Report", "row_id": 1472079, "text": "Resp Care\n\nPt remains intubated and currently vented on full support occassionally overbreathing set rate with stimulation. Attempted PS wean this shift however pt became tachycardic, and tachypnic in the mid 40s consistently and was subsequently placed back on A/C. PT transported to and from CT scan sinus/neck without any incident. ETT rotated and resecured this shift. BS course bilaterally sxing frequently for mod to large amts of loose white frothy secretions. Lots of oral secretions also present. Bronchodilators given x3 with good effect noted. Will cont with vent support and reassess for readiness to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-31 00:00:00.000", "description": "Report", "row_id": 1472080, "text": "NPN 0700-1900\nEvents: sedation off for 1/2 hour per wake up protocol, able to decrease fentanyl and versed drips. Traveled off floor x 1 hour for head and neck CT to check for possible abcess, source of infection. Tspike to 100.9PO, trial of PSV, not well tolerated by pt.\nROS: Neuro: Sedation turned off per wake up protocol, sedation restarted as patient became profusely diaphoretic, tachycardic, tachypnic, attempting to reach for ETT despite restrained wrists. Febrile to 100.9 PO, tylenol 650mg via G-tube. Pt now lightly sedate on 4mg versed/hr and 75mcg fentanyl/hr, arouses to voice, follows commands to open mouth, grasp hands and wiggle toes. Admitted to gas pain in abd, relief w/BM.\nRESP: Pt requiring at least q2hour suctioning via ETT for large to copious amts white frothy secretions. Cooperative w/mouth care for most part and also suctioning large amts clr secretions. Tolerating afrin as prescribed, sinuses reported as congested on head CT prelim, await final . done this morning when sedation off x 20minutes and starting to get agitated, 140s. Attempted PSV 22, PEEP 5, tachycardic, tachypnic and diaphoretci after 15minutes also requiring frequent suctioning. Able to get ABG on PSV 7.36/60/80, switched back to AC 500x 12, 50%,5PEEP prior to getting ABG results and pt subjectively improved though tachycardia persisted (lopressor restarted w/good initial effect). Pt on Bari Maxx II bed which has continuous turn feature which patient appears to tolerate @ times.\nCV: Noted increase in HR from 70s overnight up to low 1teens as sedation lowered. B/p also increasing to high of 130/80s, discussed w/team and metoprolol restarted 25mg (usual does is TID). Metoprol appeared initially effective, may require TID dosing again. Continues on lasix gtt @ 5mg/hr, currently -800 f/b for day, goal -1.5.\nGI: ABD large soft, denied pain w/palpation but then c/o abd pain and passed flatus w/relief. Medicated w/dulcolax PR and 1senna w/large bm as result, OB+. Tube feeds @ 25cc/hr shut off @ noon as instructed by CT tech for head and neck CT. Restarted upon return @ 1800.\nGU: foley patent, as above w/lasix drip.\nSocial: pt's mother called and requested family meeting tomorrow along w/pt's aunt @ 1300, team notified. Pt told of meeting and appeared anxious and I was unable to read her lips but able to comprehend that patient wants to be involved w/this meeting. Please hold meeting @ bedside tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-01 00:00:00.000", "description": "Report", "row_id": 1472081, "text": "MICU Nursing Note 1900-0700\nEvents: Pt's OGtube became dislodged during night even though pt mildly sedated and with bilat wrist restraints in place---no evidence of aspiration noted, New OGtube placed and awaiting CXR results to confirm placement. Remains sedated on IV Fentanyl and IV Versed. Continues on IV Lasix gtt and neg. 1300ml at MN.\n\nNeuro: Arouseable on IV Fentanyl at 75 mcgs/hr and IV Versed at 4 mg/hr, opens eyes and follows all commands with stimulation, PEARL, when not stimulated pt resting quietly, no acute neuro change noted. Moving all extremities with good strength. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes. Continues on TID Haldol dosing.\n\nCardiac: HR= 70-90's Afib with occas. PVC's noted, BP= 104-140/60-70's. Good waveform and correlation from right radial Aline. Left SC TLC site C/D/I. CVP= . Continues on IV Lasix gtt at 5 mg/hr with good diuresis.\n\nResp: Lungs remain coarse bilat. ETtube suctioned for mod amts. frothy white sputum and oral suction for same, Tol. mouth care, No vent changes overnight and remains on following vent settings: AC 500-50%-12 with Peep=5. RR= with Sats= 94-99%. ABG 7.37-65-75-39-8. TV= 450-500's and MV= .\n\nGI: OGtube initially checked by auscultation and pt with high residuals of 50 ml so tube feedings on hold during evening for 3 hours and restarted at 25 ml/hr with pt tolerating. Pt found with OGtube out although wrists restrained and pt mildly sedated---no evidence of aspiration noted. New OGtube placed and clamped at present with CXR results pending. Abd large with + hypoactive bowel sounds all quads. No BM during night.\n\nGU: Foley to CD draining clear yellow urine. Neg. 1300 ml at MN and neg. approx. 500 ml. since MN with goal for pt to be neg. 1.5 L for 24 hours. Pt with small amt rubra menses.\n\nID: Low grade temps with Tmax= 99.7. WBC= 10 this am. Continues on IV Meropenum and IV Vanco.\n\nSkin: Remains on bari-air mattress. No breakdown noted. Tolerates rotation cycle for short periods.\n\nSocial: mother and aunt have requested a family meeting for 1:00pm today to discuss pt's POC. By report pt would like to be included in meeting and meeting should take place at bedside.\n\nPlan: Attempt to wean sedation as tolerated and wean vent as tolerated, continue aggressive pulmonary toiletting, Assess pt's fluid status and adjust Lasix gtt to parameters, Replace lytes prn, Obtain CXR results and restart TF if OGtube in right place, Continue bilat soft wrist restraints to prevent pt from pulling at lines and tubes, Hold meeting at pt's bedside and attempt to wean sedation prior to maximize pt's level of understanding, Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-01 00:00:00.000", "description": "Report", "row_id": 1472082, "text": "respiratory care\npt remains intubated, no vent changes made overnight. this am was 188.9. BS coarse.sxnd for moderate amounts of white frothy secretions. MDI's given as ordered.\nPlan: wean vent settings as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-01 00:00:00.000", "description": "Report", "row_id": 1472083, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: PCN, morphine\n\nEvents: Pt continues on Lasix gtt, tolerating CPAP+PS since noon, family meeting, sedation titrated as needed for pt comfort/safety.\n\nNeuro: Pt lightly sedated on Fentanyl 75mcg/hr and Versed 3mg/hr. Arousable to voice, purposeful movement of extremities noted, inconsistently following commands. Bilateral soft wrist restraints in place for pt safety. Pt receiving TID haldol for agitation, EKG done done today showing QTc .47. Pt appears comfortable on aforementioned settings.\n\nCV: HR AFIB 74-91 with rare PVC, ABP 93-112/51-74, CVP 16-21 - goal CVP <14. Lasix drip continues at 5mg/hr. Per team continue diuresis until BUN/Creat bump. Crit stable. For access pt has right radial a-line and left subclavian TLC, both patent and WNL. Afternoon dose lopressor held due to low BP.\n\nResp: Pt on CPAP+PS since noon, tolerating well current settings 50%/+5/PS20, STV ~300, , RR 12-27 with sats >95%. ABG 7.38/64/74. Suctioned frequently for small to moderate amounts of thick, white sputum. Lung sounds clear to coarse in apices, diminished in bases.\n\nGI: BS x 4, no stool this shift. TF restarted once OG tube placement confirmed, running at 25cc/hr with moderate residuals. Per nutrition advance TF slowly q4-6h.\n\nGU: Foley patent and draining moderate amounts of clear, yellow urine. UO >70cc/hr. Pt negative 800 at this writing. Per team continue with aggressive diuresis. Pt continues to have light menses. AM lytes repleted as ordered\n\nID: Tmax 99.4 PO, continues on ABX treatment of Meropenum and Vancomycin.\n\nSocial: Family meeting this afternoon with Dr. . Plan of care for pt is to continue diuresis and re-evaluate CV and respiratory staus on Friday . If no change in pt's status family will consider trach/peg.\n\nPlan:\ncontinue diuresis\ngoal CVP <14\nwean sedation as tolerated by pt\naggressive pulmonary toileting\nroutine ICU care and monitoring\nsupport to pt and family\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-01 00:00:00.000", "description": "Report", "row_id": 1472084, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 20/5 tol well with Vt around 300s and MV 5-8L. ABG WNL on present vent settings with adequate oxygenation. Pt continues to have periods of agitation during PS wean requiring frequent sxing at times. BS dim/slightly course sxing for small to mod amts of loose white/frothy secretions. Bronchodilators given x3 with good effect. Will cont with vent support and reassess for further weaning as tol.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-02 00:00:00.000", "description": "Report", "row_id": 1472085, "text": "MICU Nursing Note 1900-0700\nEvents: pt did not tolerate CPAP+PS as evening progressed with tachypneic and pulling in small volumes---placed back on AC overnight to rest, more restless last night.\n\nNeuro: Lightly sedated on IV Versed at 3-4 mg/hr and IV Fentanyl at 75-100mcgs/hr, requiring a few boluses with activity, at times very restless and attempting to sit up and get OOB and attempts at pulling at ETtube and shaking head back and forth and trying to tongue out ETtube and Ogtube, following commands, bilat soft wrist restraints to prevent pt from pulling at tubes and lines. Continues on TID dosing of IV haldol with no lengthening of QT interval.\n\nCardiac: HR= 77-90 Afib with rare PVC noted, Left radial aline with good waveform and correlation, BP= 102-124/50-60's, Left SC TLC site C/D/I and all ports patent, Continues on IV Lasix at 5mg/hr. CVP= 13-16.\n\nResp: Lungs remain coarse bilat with pt occasionally bronchospastic after suctioning, RR up to 30-40's with poor tidal volumes on CPAP+PS during evening ----ABG essentially unchanged at that time but placed on AC overnight to rest. Current settings include 500-50%-AC=12 with Peep=5 with RR= and MV= with ABG= 7.39-63-83. Sats= 95-96%. ETtube suctioned for small amts thick white sputum. Oral suction for same.\n\nGI: OGtube placement checked by auscultation, tolerating tube feedings at 35 ml/hr with residuals 10-20ml, Abd obese and with + but distant bowel sounds all quads, no BM.\n\nGU: Foley to CD draining clear yellow urine. Remains on IV lasix gtt at 5 mg/hr with CVP at goal of 13-16. Neg. approx. 1 liter at MN and neg. 400ml since MN.\n\nSkin: intact, remains on bariair mattress---tolerates turning for short periods.\n\nID: continues to run low grade temps with Tmax= 99.8. WBC= 11.2. continues on IV Meropenum and IV Vanco and started on Afrin nasal spray and NS spray.\n\nSocial: Family meeting yesterday reportedly went well and goal is to continue to aggressively diurese pt and reassess on Friday and discuss possibility of trach/PEG if pt unable to extubate.\n\nPlan: continue aggressive pulmonary toiletting, Diurese with goal CVP= and neg. 1-1.5L/day, Decrease sedation as tolerated, Attempt to wean to CPAP+PS again today, Increase tube feedings as tolerated, Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-02 00:00:00.000", "description": "Report", "row_id": 1472086, "text": "respiratory care\npt remains intubated, curruntly vented on A/c. PSV did not tolerated, RR in 40's.Suctonied for mod amounts of white frothy secretions.MDI;s given with fair effect. this am was 200.\nPlan to wean to PSV as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-02 00:00:00.000", "description": "Report", "row_id": 1472087, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: PCN, morphine\n\nPt is 40 year old woman with history of OSA, ETOH abuse, obesity - admitted to MICU with worsening CHF (EF 40%) and respiratory failure. CXR revealed PNA, chest CT negative for PR. Pt currently intubated and sedated.\n\nNeuro: Pt arousable to voice on Fentanyl 125mg/hr and Versed 4mg/hr, bolused as needed for agitation and nursing care. Very agitated this morning required one time order haldol 5mg with good effect. Pt inconsistently following commands, spontaneous purposeful movement noted to all extremities. Pt remains in bilateral soft wrist restraints for safety. Pt denies pain.\n\nCV: HR AFIB 77-91 with occasional PVC, ABP 96-117/54-72, CVP 11-13 (goal is <12). Pt continues on Lasix drip at 5mg/hr, per team will continue to diurese until bump in creatinine seen. Pt has right radial a-line and left SC TLC for access, both patent and WNL.\n\nResp: Pt remains intubated and on vent support. Switched to CPAP+PS this AM, continues to do well at this writing. Settings are CPAP+PS 50%/+5/PS20 with ABG of 7.37/63/74, team aware of results. RR 20's with sats >94%, STV ~300, MV . Suctioned x 4 for small to moderate amounts of thick, white secretions. Lung sounds coarse to diminished.\n\nGI: BS x 4, no stool this shift. Pt tolerating TF, advanced to 40cc/hr (goal 45) with residuals 10-30cc. Per nutrition advance slowly. OG tube patent, placement checked.\n\nGU: Foley patent and draining adequate amounts of clear, yellow urine. UO 40-180cc/hr. Goal is to have pt 1L to 1.5L negative at MN, currently negative 600cc. AM K repleted. Lasix drip running at 5mg/hr.\n\nID: Tmax 99.3, continues on ABX therapy and nasal sprays for PNA and sinusitis. Blood cultures from pending.\n\nSocial: Daughter in to visit today and mother called, updated on pt's condition and plan of care. Family meeting scheduled for Friday to reassess pt's plan of care.\n\nPlan:\npulmonary toileting\ncontinue diuresis, goal CVP <12\nsedation as needed for pt comfort/safety\ncontinue CPAP+PS\nmonitor for bump in BUN/Creat\nadvance TF as tolerated\nroutine ICU care and monitoring\nsupport to pt and family\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-02 00:00:00.000", "description": "Report", "row_id": 1472088, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. Pt has been on PSV most of shift with TV 200-400 range, ABG's withing acceptable range. Albuterol and Atrovent MDI's as ordered. cont support.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-03 00:00:00.000", "description": "Report", "row_id": 1472089, "text": "respiratory care\npt remains intubated, curruntly vented on A/C. Pt with low Vt in 200's late pm this shift and techypnic in 40's, A/C initiated. ABG acceptable compare to pt's baseline ABG's.Breath sounds coarse, diminished at bases.Suctioned for moderate amount of white frothy secretions.ETT retaped and repositioned. this am was 133.\nPlan: PSV in am, monitor respiratory status closely.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-19 00:00:00.000", "description": "Report", "row_id": 1472157, "text": "Nursing Progress Note 1900-700\n\nNeuro: Remains lightly on Fentanyl 75 mcg/Versed 4 mg. Agitated at beginning of shift, mouthing words, throwing legs over side of bed. Medicated with 2 mg IV ativan with good effect, much calmer overnoc, sleeping in naps. MAE, PERRLA.\n\nCardiac: Hemodynamically stable with BP's ranging from 100-120/60-70's. Remains in afib with rate varing from 70-110's with occ PVC's. +2 pt/dp bilaterally\n\nResp: Trached with # 7 bovona. RR up to 40's at 0200 volumes down so pressure support increased to 20. Current vent settings 20/+10/40% with rr 25-32. TV290-310, MV . Lung sounds coarse diminished at bases. Suctioned Q 3 hours for moderate amounts of thick light yellow secretions\n\nGI: Tolerating TF at goal of 45 cc/hr (nutren renal with beneprotein), Abdomen soft obese + BS in 4 quadrents. No BM this shift\n\nRenal: Foley draining adequate amounts of clear yellow urine. + 900 cc at midnoc so additional 40 of lasix given with moderate effect. Currently even on I&O's.\n\nID: T max 100, continues on Vanco/cefepime. WBC trending down. Vanco trough pending\n\nSKin: perineal area exchoriated but intact.\n\nSocial: No calls from family over noc, remains full code\n\nPlan:\n\n1. Continue slow wean on sedation\n2. Wean vent settings as tolerated\n3. Follow temp ANBX as ordered\n4. Routine ICU monitoring and care\n" }, { "category": "Nursing/other", "chartdate": "2184-06-19 00:00:00.000", "description": "Report", "row_id": 1472158, "text": "REsp CAre\nPt remains trached with # 7.0 on PSV 16/10 vts ranging 380-450 rr 13-28. BLBS slightly course improved with suctioning of sm amt thick white secretions, MDI geven per order. Plan to remains on PSV and wean IPS and peep as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-19 00:00:00.000", "description": "Report", "row_id": 1472159, "text": "Nursing progress notes 0700-1900\nNeuro: Remains trached and vented, mildly on Fentanyl 75 mcg/hr and Versed 4mg/hr. , tried to communicate with , encouraged by writings and visual aids but were not able to make it. Opens eyes spontaneously, purposeful movements of all extremities. Agitated at the begining of shift, appears anxious and throwing legs out to the side of bed, medicated with Ativan 2mg with fair effect. Haloperidol 5mg IV started TID for increased agitation with good effect.\n\nResp: Received on vent settings CPAP with PS 20, PEEP 10, fio2 40%, RR 13-29, sat 97-100%, PS decreased to 16 in the afternoon. Current vent settings PS 16/+10/40%, Suctioned q 3-4 hrs, moderate pale yellow thick secretion. LS coarse to diminished bases, repositioned frequently.\n\nCardiac: HR 68-94,remains in a-fib with occasional PVC's. SBP 104-147, cont on Metoprolol and Captopril. Captopril decreased to 6.25mg. Coag sent, INR 1.6, Coumadin increased to 7.5mg.\n\nAccess: LSC TLC.\n\nGI/GU: Abdomen soft distended, +BS, TF 45 ml/hr (Nutren renal with beneprotein), minimal residual, no BM this shift, contd the bowel medication. Urine output minimal, improved after Lasix 20mg IV, 30-380ml/hr.\n\nID: Tmax 100.4, cont on Vancomycin and Cefepime. Vanc trough level 17\n\nSkin: Excoriated skin in the perineal area.\n\nSocial: Tried to contact mother per request, left the message to call back, but no calls received from family till now.\n\nPlan: Cont to wean slowly from sedation as tolerated.\n Cont to wean from vent as tolerated, needs pulmonary toileting.\n Emotional support to the Pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-15 00:00:00.000", "description": "Report", "row_id": 1472139, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA.\n\n40 YR OLD FEMALE WITH OBESITY, CHF, AND AFIB ADMITTED WITH PROGRESSIVE SOB, HYPERCARBIA, HYPOXIA/ NOW S/P TRACH AND PEG, REMAINS VENTED AND FEBRILE.\n\nPT LIGHTLY WITH FENT 75MCG/ MIDAZ 4MG. REQUIRES BOLUS OF VERSED DURING CARE. PT SLEEPS IN LONG NAPS, AROUSED ON VOICE STIMULATION, FOLLOWS COMMANDS INCONSISTENTLY, MAE IN BED.\n\nHEART RYTHM AFIB WITH CONTROLLED RATE, HR:70S-80S WITH OCC ECTOPIES, REMAINS ON METOPROL AND CAPTOPRIL. SBP 110S-130S/ MAP 70S-80S.\nRECEIVED FUROSEMIDE 40MG IV WITH GOOD EFFECT/ DIURISES APPROX 1000CC OF URINE POST LASIX/ FLUID BALANCE NEG 100CC POS MN/ GOAL:NEG 500CC.\nFEBRILE/ TMAX 101.3/ TEAM AWARE/ TYLENOL GIVEN/ BLOOD CX X1 SET SENT.\nMULTIPLE CX PENDING/ WBC UP 16 (12), REMAINS ON FLAGYL FOR PRESUMED CDIFF, THOUGH STOOL CX NEG FOR CDIFF.\n\nREMAINS VENTED AC/450/40%/ 10 OF PEEP. LUNG SOUNDS COARSE THROUGHOUT/ RECEIVED MDI PER RT. SUCTIONED AT TIMES MODERATES AMOUNT OF WHITE-YELLOW THICK SECRETIONS/ SATO2:96-98%. ABGS TO BE SENT/ PS WITH BE TRIALED THIS AM. CHEST XRAY POS FOR PULM EDEMA AND R SMALL EFFUSION ON .\n\nABD OBESE, POS BS/ PULM BENEPROTEIN AT GOAL RATE:45CC/HR. NO RESIDUAL. NO BM THIS SHIFT/ REMAINS ON BOWEL REGIMEN.\n\nFOLEY PATENT\n\nSKIN W/M. SKIN CARE DONE/ ON MAXXAIR BED/ REPOS Q 2HR.\n\n MOTHER, STEP FATHER, NEPHEW VISITING LAST PM. PT HAS TEARS WHILE INTERACTING WITH HER MOTHER. PT AND FAMILY MEMBERS REASSURED.\n\nCONT CURRENT \n" }, { "category": "Nursing/other", "chartdate": "2184-06-15 00:00:00.000", "description": "Report", "row_id": 1472140, "text": "RESP CARE NOTE\nPATIENT AGITATED THIS AM. SUCTIONING THICK YELLOW SECRETIONS. ALB/ATR GIVEN Q4. NOT DONE SECOND TO 10 OF PEEP. ABG DRAWN, RESULTS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-15 00:00:00.000", "description": "Report", "row_id": 1472141, "text": "07:00-19:00\nNEURO:Remains on Versed/Fentanyl .Pt is alert,moving all four limbs.Reassurance given.No episode of anxiety.\n\nPULM:Remains on AC mode.Reduced tidal volume to 400 and RR to 10 because CO2 was low this am as ptis CO2 retainer.Remains on PEEP of 10.SaO2>95%.Thick yellow secretion on suction.Lung sounds clear-coarse.\n\nCVS:Remains in Afib with rate 70-100.BP stable.CVP 4-21.Lasix 40mg given,CVP down to 4 from teens.\n\nGI:On Nutren Pulmonary Full strength 45 mls/hr with minimal residual.Bowel movement this am @700mls.Bowel sounds positive. obese.\n\nGU:U/O 30-400mls/hr.\n\nLABS:Temp 99.2-100.7.Continues on Flagyl.Stool sent for Cdiff.Sputum and bld cultures pending.\n\nSOCIAL:no phone enquiries.\n\nPlan:Wean vent/sedation as tolerated.Monitor temp.Follow ABGS.Aim for neg balance @ 1lit.Keep family up to date with .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-15 00:00:00.000", "description": "Report", "row_id": 1472142, "text": "Respiratory care\nPt remains trached with # 7 , pt continues on a/c vent tidal vol weaned to 400, rate decreased to 10, ABG attemped on these settings, Pt refusing stick. Mini-BAL done at bedside and sent to lab. Suctioning large amts of yellow secrections, MDI as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-05 00:00:00.000", "description": "Report", "row_id": 1472101, "text": "Nursing progress notes\nReview of systems:\n\nNeuro: pt sedated but arousable on fentanyl 125mcq/hr and versed gtt 6mg/hr. she follows commands inconsistantly. perl 3mm brisk\n\nResp: pt orally intubated at 24 lip line, she tried x 2 to self extubate last evening. pulled to 24 last night and is ok placement per micu attending. ls clear w/ diminished bases. sucitoning clear to white secretions from ett. was on ac this am now on cpap 50% vbg obtained. co2 have been running in 60s.\n\nCV: tele slow afib this am 50-60s w/ pvcs k+ 3.8 repleted. now hrt rate 80-90s pt on lopressor 25mg and captripril tid. lasix gtt at 10mg/hr this am. this afternoon uop dropped off to 45cc/hr from 60-120cc/hr sbp dropped to 88, cvp 12 (goal) from 18-20. lasix gtt decreased to 5mg/hr the next hour uop down to 15cc/hr. lasix gtt off for now. k+ 3.6 will replete again w/ 40 meq of kcl via ngt.\n\ngi: abd obese bs+ ogt in place (she has pulled it out 3 times b/t last night and yesturday.) tube feeding at goal 45cc/hr residual <5cc/hr\npt on lactalose tid to help facilitate bm\n\ngu: uop as stated above has dropped off to 15cc/hr will cont to monitor\n\nskin: intact except for b/t inner thighs, skin seems to be sloffing off. cream applied. pt on bariair bed\n\nendo: bs wnl\n\nid: pt on vanco and merepenem for sinusitis and for +bc and pna\nt max 100.7 tylenol given pt was pan cx last evening.\n\ncode: full\n\nsocial: no contact from the family this shift. plan for family meeting on monday for ? trach and peg\n\nplan:\n\nmonitor uop and place lasix gtt back on as needed\nplace on cpap 15/10 at night to rest.\ndraw vbg as needed\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-30 00:00:00.000", "description": "Report", "row_id": 1472074, "text": "Respiratory Care: Pt remains intubated and vented. No parameter changes made this shift. Received MDI's. BS coarse. Attempted morning RSBI, but pt with no spontaneous respirations. When not sedated, pt is very agitated.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-30 00:00:00.000", "description": "Report", "row_id": 1472075, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 500 x 12 5P 50%. MDI's given. ETT retaped and repositioned. No other changes noted.\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-04 00:00:00.000", "description": "Report", "row_id": 1472096, "text": "RESPIRATORY CARE: PT REMAINS W/ 7.5 ORAL ETT IN\nPLACE. PLACED ON PS .50 THIS AM. ABG STABLE\nDESPITE 150-160 ON PS 10. INCREASED TO PS 15/10\nAT 1700. SX FOR WHITE SPUTUM. ALBUTEROL/ATROVENT\nMDI'S GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-04 00:00:00.000", "description": "Report", "row_id": 1472097, "text": "Nsg addendum\nPTT 39.4 Heparin gtt increased to 1600 u/hr check repeat PTT 10 pm urine continues to be hematuric. flushed with sterile water - no clots.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-06 00:00:00.000", "description": "Report", "row_id": 1472102, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\n40 YR OLD FEMALE WITH OBESITY HYPOVENTILATION, CHF, AFIB, RESP FAILURE\nADMITTED WITH SOB AND HYPOXIA. ADMITTED TO MICU FOR FURTHER MNGT.\n\nPT REMAINS SEDATED ON FENT 125MCG/ MIDAZ 6MG. NO PERIOD OF AGITATION, NO NEED FOR BOLUS THIS SHIFT. OPENS EYES ON VERBAL STIMULATION. OBEYS COMMANDS WHEN SEDATION OFF. MAE PURPOSEFULLY.\n\nREMAINS INTUBATED, CPAP 15/10 TO REST THROUGH NIGHT. TOLERATES WELL, MAINTAINS SATO2 94-96%. LUNG SOUNDS CLEAR IN UPPER AIRWAYS/COARSE AT BASES. SUCTIONED AT TIMES MODERATE AMOUNT OF THICK WHITE SECRETIONS.\nCO2 REMAINS HIGH:42 (45).\n\nHEART RYTHM AFIB/ HR 50S-60S WITH OCC ECTOPIES/ SBP: 90S-100S/ MAP 60S-70S/ 0400 METOPROL DOSE HELD IN SETTING OF LABILE HR AND BP/.\nUOP MARGINAL/ 15-40CC/HR. LASIX REMAINS ON HOLD. BUN/CREAT:30/1.1\nLOW GRADE TEMP/ TMAX:99.2. CONT ON MEROPENEM AND VANCO/ WBC SLIGHTLY HIGHER:12.8(12.5)\nH/H STABLE\n\nABD OBESE/ POS BS/ NO BM. RECEIVED COLACE AND LACTULOSE/ OGT IN PLACE DELIVERING PULM BENEPROTEIN AT 45CC/HR/ NO RESIDUAL.\n\nFOLEY PATENT, DRAINING CLEAR YELLOW URINE/ NO HEMATURIA.\n\nSKIN W/D, SKIN CARE DONE/ON BAIRAIR BED.\n\nFAMILY VISITED LAST EVENING/ INTERACTS APPROPRIATELY.\n\nCONT CURRENT POC\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-18 00:00:00.000", "description": "Report", "row_id": 1472152, "text": "respiratory care\npt remains trached, no vent changes made this shift. CAT scan results confirms LLL PNA. BS coarse and diminished at bases.Suctioned for moderate amounts of yellow thick secretions.Pt gets techypnic at times.MDI's given as ordered.\nPlan: Wean PS as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-18 00:00:00.000", "description": "Report", "row_id": 1472153, "text": "Nursing progress notdes 0700-1900\nEvents: New central line, LSC TLC.\n Fluid bolus for low BP.\n\n\nNeuro: , , opens eyes spontaneously, mouthing words, anxious at times. on Fentanyl 75 mcg/hr, Versed 4 mgs/hr. Pt was calm and co-operative at the begining of the shift, Lorazepam 2mg PO given PRN for increased anxiety with good effect. Pt was agitated at times, s/b physiotherapist, made her to sit up in bed at the edge of bed, tried to pull out the tracheostomy tube, refixed and inflated cuff, confirmed by chest x-ray. Soft restraints on limbs x 4, cont on sedation at the same rate.\n\nResp: Received on CPAP+ PS 16, PEEP 10, fio2 40%, RR 18- 27, LS coarse, diminished bases. Sxn moderate, yellow thick secretion.\n\nCv: HR 76-96, a fib with occasional PVC's. SBP 96-146, MAP 60-80, cont on Metoprolol and Captopril. Na 142, K 3.5, repleted with 40 meq kcl PO. RSC TLC for IV access. Tmax 99.8, cont on Vancomycin and Cefepime. Fluid bolus NS 500ml given low BP.\n\nGI/GU: abdomen obese,+BS, TF 45 ml/hr, minimal residual. No BM this shift. Foley draining yellow urine, adequate amount, Lasix 40 mg given x 1 dose, diuresed after Lasix. Fluid restriction to 2 liters/day.\n\nSkin: Intact.\n\nAccess: New central line, LSC, TLC inserted today.\n\nSocial: No calls from the family today.\n\nPlan: Wean off sedation as tolerated by the Pt.\n Wean PS/PEEP as tolerated .\n Follow up culture data.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-18 00:00:00.000", "description": "Report", "row_id": 1472154, "text": "Resp Care\n\nPt had incident where trach was partially dislodged. Trach was advanced without incident. When at rest mv in the 6-8L range with tv's in the low 300's. When anxious rr and mv increase. Spo2 in the high 90's. Suctioning thick yellow\n" }, { "category": "Nursing/other", "chartdate": "2184-06-18 00:00:00.000", "description": "Report", "row_id": 1472155, "text": "Addendum\nLeft SC placement confirmed by chest x-ray, RSC d/c'd, catheter tip for c/s sent.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-30 00:00:00.000", "description": "Report", "row_id": 1472076, "text": "Pt is sedated on Midazolam 7ml/hr and Fentanyl had to increase from 125mls/hr to 150 as pt was very restless in the morning.Also needed several boluses of midazolam and Fentanyl.Moves all four extrimities,does not follow commands.Pt remains on both limb restraints.\n\nRESP:Remains on current settings.RR 12/min. SaO2>95%\n\nCVS:Systolic BP b/w 110-90.Remains in Atrial Flutter.Increased Lasix from 5 to7mg/hr,aiming a negative balance of 1 litre.\n\nGU:Passing clear yellow urine 80-220mls/hr.\n\nLABS/MICRO:Had 40 meq of KCL for K+ of 3.9.Blood cultures done from Art line and Central line.Continues on Meropenum and Vancomycin.Temp up to 100.7,Acetaminophen given PRN.\n\nGI:No bowel movement this shift.Continues on Colace and PRN senna.Abomen soft and bowel sound present.TF stopped for several hours as residual >100mls.Commenced it back at 30mls/hr.\n\nSKIN:Surfaces grossly intact.No edema noticed.\n\nSOC:Mother updated by team intern on pt condition and plan of care.\n\nPLAN:\n-titrate sedation prn for comfort /aggitation\n-RSBI in am ?wean settings\n-continue Lasix gtt and follow K+ repeat prn\n-recheck residual advance TF rate to goal 45cc/hr as tolerated.\n-tenative family meeting on Wednesday morning to discuss pt condition and possible tracheostomy.\n\n RN\n" }, { "category": "Nursing/other", "chartdate": "2184-05-31 00:00:00.000", "description": "Report", "row_id": 1472077, "text": "1900-0700 rn notes micu\n\nevents: in the evening pt dropped BP 84=85/50 with MAP 55-58, decraesed sedation Fentanyl 125mcg/hr, versed 5mcg/hr and stopped Lasix gtt fro 2hr, restart at rate 5mg/hr. curerntly BP at 100's with MAP>60.\n\nneuro: receieved seadted on Fentanyl 150mg/hr and versed 7mg/hr, as asys above decraesed sedation, cont Halidol IV tid, pt response to pian ,does not follw commands, at itme opens eyes to pain. remains restrainse for safety.\n\nresp: remains intubated, on AC 50%/12/500/peep 5, pt does not OVB, ABG:7.38/71/85/44, no changes from priviuos ABG. LS coarse clear to suction. pt has white moderate amount secretions. no RSBI-pt did not initiate any spont breathing.\n\ncv: HR 70-80;s, Aflutter, with occas PVC's,pt has several episodes of bradicardia 56-58, MD aware,K 3.8,repleted with40meq potassium, morning K=4.2. currently BP 99-111/60's with MAP >60. HCT stable at 38-40.\n\ngu/gi: foley in place, draimge yellow/clear urine, recieved on LAsix 7mg/hr, decreased to 5mg/hr d/t low BP, pt neg 1400cc for 24 hr, goal 1.5L neg. cont TF, but was stopped for a few hr d/t residual 90cc, restart TF at 25cc/hr. ABD soft/obese, no BM this shift.\n\nid: afebrile, BX from Aline on gram pos cocci, sent another set of BC from A-line. cont meropenem and vanco.\n\naccess: Aline, LSC intact.\n\nsocial: full code, no contact from family this shift.\n\nplan: cont monitoring neuro/resp/cardio status\n keep MAp>60\n titrate Lasix to keep neg 1.5L\n amily meeting on Wensday about cont treatment.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-05 00:00:00.000", "description": "Report", "row_id": 1472098, "text": "Nursing progress notes 1900-0700\n\nEvents: A- line d/c'd.\n\nNeuro: Agitated early in the shift, tried to pull out the tubes, sedated with Fentanyl & Versed bolus. Midazolam drip increased to 6mg/hr and Fentanyl 125 mcg/hr with few boluses. Pt was sedated comfortably for couple of hrs. Early morning awake and agitated, sedated with boluses. MAE, eyes opens spontaneosly and trying to talk when awake. Follows commands inconsistently. Both hands soft restraints on for safety.\n\nResp: Recieved on CPAP+PS 15/+10, fio2 50%, sat 95%, RR 28-30's. Pt tried to pulled out the ET tube early in the shift. Vent settings changed to assist controll with fio2 50%, TV 500, PEEP 10, RR 12/min, sat 93-95%, X-ray chest done to confirm. Sxn for moderate white thick secretions via ETT. LS coarse to diminished bases.\n\nCV: HR 64-100/min, a-fib/ a-flutter with occasional PVC's. A- line was dampened and no backflow, team notified. A-line d/c'd and attempt failed for another A-line. Heparin drip d/c'd due to heavy heamaturia. CVP 14-15, goal<12, cont on Lasix drip 10 mg/hr. Urine output 50- 100 ml/hr with positive balance, Hydrochlorothiazide 500mg x 1 IV given with good effect.\n\nGI/GU: Abdomen obese, +BS, no BM this shift.TF 45ml/hr with minimal residual. OGT was pulled out once by the Pt, reinserted, placement checked by x-ray. Foley patent, pink urine with sediments. Urine became more clear now.\n\nID: T max 101.2, blood c/s sent, sputum c/s sent,Tyenol 650 mg PO given. Cont on antibiotics( Vanco/Meropenem).LSC TLC for access.\n\nSocial: No calls from the family tonight.\n\nPlan: Cont with pulmonary toileting\n wean vent as tolerated\n sedation for comfort and safety\n cont to diures with CVP goal < 12, monitor for bump in creat\n for ? trach/peg soon.\n For A- line placement by the team.\n For blood c/s second set.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-05 00:00:00.000", "description": "Report", "row_id": 1472099, "text": "Resp care: Pt continues intubated, agitated >> pulled out oett/replaced and repositioned, secured @ 25 @ lip with placement confirmed by etco2/bbs/cxr; sedated and on a/c overnoc maintaining spo2 93-97%; bs coarse crackles, sxn thick white/tan secretions, rx with mdi albuterol/atrovent, held d/t peep level, will cont support.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-05 00:00:00.000", "description": "Report", "row_id": 1472100, "text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nPS 15/10 .50 LAST NITE TO REST AND PLACED BACK\nON PS .50 DURING DAY FOR EXERCISE. SX FOR\nWHITE SPUTUM. ALBUTEROL AND ATROVENT MDI'S\nGIVEN. TRACH BEING D/W FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-19 00:00:00.000", "description": "Report", "row_id": 1472156, "text": "Resp care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct mod th pale yellow sput. MDI given as per order. Pt prently in NARD; had episode tachypnea relieved with in PSV level. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-24 00:00:00.000", "description": "Report", "row_id": 1472047, "text": "CCU Progress Note:\n\nThis is a 40yr old female with PMHx of Afib, CHF, and obesity who presented to the ER with SOB (Pt has experienced progressive dyspnea for the last 2 months)- SpO2 85%- Rx with O2- CTA negative for pulmonary emboli but (+) PNA- started on levoquin and admitted to 3- @ 4am this morning, nurse noted Pt's heart rate trending up- desaturating to the 70's- diaphoretic- restless- ABG 7.22-- lasix 20mg IV given- AM cardiac meds given transferred to CCU (MICU border) for further management.\n\nS- \"I don't want a mask on my face!\"\n\nO- see flowsheet for all objective data.\n\nresp- Pt refused BIPAP once admitted to ICU- Arrived in O2 4L via NC-\nlung sounds diminished throughout- tachypnec- SpO2 95- 98%- seen by MICU team- CXR showed CHF- diuresed well from lasix- R radial A line inserted- ABG 7.31-78-80-41- O2 decreased to 2L via NC- plan is to place Pt on BIPAP tonight @ HS.\n\n\ncv- Tele: Afib HR in 90's initially- HR 50's since 11am- B/P 104-126/65-90 MAPs 77-98- K 4.1- INR 1.9- DDimer 1845- Hct 45.3-\n\nneuro- very anxious- on CIWA scale- became very agitated this afternoon, requiring ativan 1mg IV- cooperative after being medicated- moving all extremities- follows command- amb well with 1 assist.\n\ngi- abd obese- (+) bowel sounds- taking Po without incident- no BM today- glucose @ 1700 was 100.\n\ngu- foley draining yellow to amber colored urine- U/O trended down this afternoon- repeat lasix 20mg IV given @ 1600- (-) 700cc since 12am- goal is 1-2 L- BUN 15 Crea 1.2\n\ncomfort- med for comfort- follow CIWA scale- having menses- fan on in room for c/o \"hot flashes\".\n\nID- afebrile- WBC 15- U/A (+)- PNA.\n\nA- hypercapnea probably due to obstructive sleep apnea, CHF & PNA\n\nP- monitor vs, lung sounds, I&O and labs- begin BIPAP @ HS- follow ABG's- pan culture for temp spike- offer emotional support to Pt- keep updated on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-25 00:00:00.000", "description": "Report", "row_id": 1472048, "text": "Resp Care Note, Atempted to put pt on nasal cpap. Pt unable to tol. Says it's making her sick.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-29 00:00:00.000", "description": "Report", "row_id": 1472071, "text": "MICU 6 NSG 7A-7PM\nRESP--PT REMAINS ORALLY INUTB ON AC 12 500 PEEP 5 50%. BREATHING OCCAS OVER SET RATE. SX'D Q2-4 VIA ETT FOR THICK YELLOW SECRETIONS, AND HOURLY VIA MOUTH FOR COPIOUS TAN FOUL SMELLING SECRETIONS. TEAM AWARE AND PT ORDERED FOR AFRIN AND NS NASAL SPRAYS. MOUTH ALSO NOTED TO HAVE THRUSH, NYSTATIN S&S STARTED.\n\nNEURO--PT CONTS ON FENT AND VERSED GTT. DUE TO LOW BP GTT WEANED, FENTANYL CURRENTLY AT 125MCG/HR AND VERSED 5MG/HR. PT NOT FOLLOWING COMMANDS, OPENS EYES TO VOICE. RESPONSE TO ANY STIMULI IS TO THRASH IN BED, AND ATTEMPT TO PULL AT TUBES/LINE. REMAINS RESTRAINED FOR SAFETY.\n\nCV--REMAINS IN AFIB HR 60-120, NO ECTOPY NOTED. PT WITH INC HR WHEN AWAKE. LOSARTAN AND DILT D/C'D DUE TO LOW BP. RIGHT RAD ALINE POSITIONAL AND DAMPENED AT TIMES. BP 85-150'S/. LASIX GTT RESTARTED AT 5MG/HR, WITH POOR RESPONSE. DIAMOX 500MG IV BID STARTED, WITH FAIR RESPONSE. PT CURRENTLY ~+100CC FOR DAY. TYLENOL 650MG PO X1 GIVEN FOR TEMP 100. CIPRO D/C'D. KCL REPLETED THIS , PLANS FOR RECHECK LYTES THIS PM. QTC CHECKED, CONTS ON HALDOL TID.\n\nGI--ABD SOFT, OBESE, NO BM ? SINCE ADMIT. RECEIVED DUCOLAX SUPPOS AND SENNA, NO RESULTS YET. TF RESIDUALS IMPROVING AND PT ADVANCED TO GOAL ON TF, 45CC/HR. FS REMAINS WNL.\n\nGU--FOLEY CATH REMAINS IN PLACE, DRAINING CLEAR YELLOW URINE. DIURECTICS RECIEVED AS ABOVE.\n\nSOCIAL--RECIEVED PHONE CALLS FROM DAUGHTER AND PT'S MOTHER. UPDATED ON CONDITION OF PT.\n\nPLAN--LYTES 1700\n--LASIX GTT, DIURESE AS ORDERED\n--QTC\n" }, { "category": "Nursing/other", "chartdate": "2184-05-29 00:00:00.000", "description": "Report", "row_id": 1472072, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 500 x 12 5P 50%.\nMDI's given. Pt suctioned for thick tan plugs. Pt becomes very agitated when stimulated. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-14 00:00:00.000", "description": "Report", "row_id": 1472136, "text": "Respiratory Care\nPt remains trached on ventilatory support. Able to tol PSV until 03:20 when pt noted to have increased coughing, upper airway wheeze most pronounced with cough, increased congestion, and tachycardia. Pt appeared somewhat agitated during this time. Tahcycardia medically addressed, sedation given, pt suction and treated with inhalers as ordered with improvement in BS, and vent support increased from PSV to A/C (see CareVue for details). Pt gradually improved. No AM trial due to tachcardia and peep of 10. Plan is to continue and provide vent support as needed and wean when possible.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-14 00:00:00.000", "description": "Report", "row_id": 1472137, "text": "Respiratory Care Note\nPt received on AC as noted. BS coarse and diminished bilaterally - pt has an occasional wheeze trach and in upper airway when agitated. Pt suctioned for moderate amts thick, white to pale-yellow secretions. Pt weaned to PSV 20/10 - pt tolerated well for several hours, but became increasingly tachypneic 45-52 with VT's mid 200's. Pt was subsequently placed back on AC. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-14 00:00:00.000", "description": "Report", "row_id": 1472138, "text": "07:00-19:00\nNEURO:Pt is alert moving all four limbs.Remains on Midazolam/Fentanyl .Pt can be restless at times.Haloperidol given TID+Ativan given PRN.Pt was sat at the edge of the bed.Tolerated for few mins.\n\nPULM:Remains vented on AC mode with RR 14/min PEEP 10 O2 40%.Tried on CPAP for hour and a half but pt was tachypneic with RR 40-50/min.SaO2>95%.Lung sounds coarse clear and diminished.Yellowish thick secretion on suction.\n\nCVS:Remains in Afib with HR 80-120.BP stable.CVP 15-22.Lasix 40mg IV given.\n\nGU:Passing urine 30-500mls/hr(post Lasix).\n\nGI: soft.BS+ve.Loose bowel movements this pm.\n\nID:Temp 99.9-100.8.Continues on Flagyl.Sputum and stool specimen sent for c/s.\n\nSOCIAL:Phone enquiry from daughter.Updated re pt condition.\n\nPLAN:Aim for 500mls negative balance.Follow up culture report.Continue vent wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-17 00:00:00.000", "description": "Report", "row_id": 1472150, "text": "Nursing Progress Note:\n\nNeuro: Pt. received on 75mcg/hour Fentanyl and 4mg/hour Versed. Decision on rounds to begin weaning sedation and converting to PO Ativan. 2mg Ativan ordered q 8 hours, one dose given. Sedation decreased to 50mcg/hour Fentanyl and 2mg/hour Versed which pt. tolerated for several hours. During this time pt. was alert and mouthing words which could be understood with time, smiling and following commands, assisting with turns. Pt. indicated that she wanted to leave and that she wanted to speak with her mother. In late afternoon pt. started becoming more restless, 2mg IV Ativan given and Versed increaased to 3mg/hour. Team aware and OK'd giving prn doses of Ativan to try to keep weaning sedation. Pt. was OOB to chair for 2 hours and was drowsy in the morning but awake for the rest of the day.\n\nCV: HR 70s-100s a-fib (flutter at times?), NBP 100s-130s/60s-90s. Captopril and Lopressor doses both increased. R SC TLC slightly reddened at site with some bleeding noted.\n\nResp: RR teens to 50s, Vent settings are now CPCP+PS 40%/16/10 (pressure support lowered from 18). Lungs are still course but have improved since morning. Pt. requires frequent suctioning of moderate amounts of thin, white secretions.\n\nGI: BSX4, tube feeds at 45cc/hour but were shut off several times during the day to patient sliding down in bed and ending up supine.\nNo residuals, no BM on shift, bowel meds held.\n\nGU: UO initially brisk but became steady at 30-40cc/hour. Diuresis discussed at rounds but no aggressive measures ordered.\n\nID: Pt. with low grade temp Tylenol given with little change.\n\nSkin: Intact\n\nSocial: Mother and spoke to pt. on phone and said she would be in today. No visitors yet.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-18 00:00:00.000", "description": "Report", "row_id": 1472151, "text": "Nursing progress notes 1900-0700\nwritten at 0435 am\nreview carevue for all other additional data\n\nno significant events overnight\n\nNeuro: At the begining of shift patient is more awake and agitated and was trying to come out of bed and sedation back to versed 4mg/hr and fentanyl 75 mcg/hr gtt and also continued regular po lorazepam. Following commands inconstitently and MAE. Denies pain. Bilateral wrist restraints are in place for safety.\n\nResp: , continued on CPAP and PSV 16 and peep 10 and no done with peep of 10. Bilateral lung sounds coarse and clear and diminished at the lt base, with thin yellow/whitish secration.\n\nCv: a fib, with occasssional pvc's. sBp 100-160's. Continued and po captopril and po lopressor. Awaiting am labs, free water bolus changed to 100 q6hrs.\n\nGU/gi: tolerating TF at goal 45 ml/hr, with minimal residul, Bs present, no bm this shift. Lasix 40 mg given with good diuresis and fluid restriction to 2L/a day.\n\nSkin: Intact\nID t max 99.8 and continued vancomycin and cefepime.\nsocial: No calls from family.\n\nplan: Wean sedation as tolerated and continue po lorazepam\n F/u cx results and monitor temp spikes\n ? wean peep and psv as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2184-06-08 00:00:00.000", "description": "Report", "row_id": 1472113, "text": "Nursing progress notes 0700-1900\nEvents: Pt remains sedated on Fentanyl and Versed gtt, Lasix gtt d/c'd, seen by thoracic surgeon consent taken from the mother via telephone for the TRACH/PEG insertion possibly on Thursday. No vent changes made. Fluid bolus increased to 150 ml q 4hrs. K+ repleted.\n\nNeuro: Opens eyes and able to follow commands , , makes good eye contacts and attempts to talk on stimulation. Soft restraints on bilateral wrists, did not make any attempts to grab the tubes today. Fentanyl 125 mcg/hr and Versed 6 mg/hr, Pt occasionally requires bolus doses of each during activity.\n\nResp: Remains intubated and no vent changes made, current vent settings on AC 500/50%/12/+10, sat 93-100%, LS coarse, sxn small to moderate thick white secretions via ETT and minimal oral secretions.\n\nCV: HR 71-86/min, a fib/ a flutter with occasinal PVC's. SBP 101-130, left SC TLC patent, site dry/intact. Na 144, K+ 3.9, Hco3 44, repleted with K 20 meq PO. IV Lasix d/c'd. CVP 12-16\n\nGI/GU: Abd obese, +BS, mushroom catheter patent, draining liquid stool in moderate quantity. TF Pulmonary Nutren 45 ml/hr. Residual minimal, placement checked. Foley catheter draining yellow clear urine 30-180 ml/hr. Urine output low since Lasix gtt d/c'd. Fluid bolus increased to 150 ml q 4hrs.\n\nSkin: Grossly intact, on bari-air bed.\n\nSocial: Called mother and discussed , consent taken for TRACH/PEG insertion.\n\nPlan: For TRACH/PEG tube insertion on Thursday.\n Cont pulm toileting.\n Emotional support to Pt and family.\n Wean sedation and vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-08 00:00:00.000", "description": "Report", "row_id": 1472114, "text": "Respiratory Care\nBreath sounds diminished and bilateral expiratory wheezes, suctioned intermittently for moderate amounts of thick white secretions, treated with Albuterol and atrovent inhalers, was diaphoretic, afebrile, into A-fib and A-flutter most of the day, had occasional PVCs, patient was fluid negative 500cc, Lasix PRN ordered with goal to get to 1L fluid negative, no ABGs nor vent changes made , we will continue to provide ventilatory support while patient awaiting Trach and Peg.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-09 00:00:00.000", "description": "Report", "row_id": 1472115, "text": "Resp Care Note\n\nPt again self extubated, either by pulling tube of perhaps by tongueing ETT forward. She had rapid desaturation to 70's and HR increassed to 175. Old ETT was pulled out remainder of the way to allow for bag - mask ventilation while anesthesia was on the way. New # 7.5 ETT was placed, again positioned @ 23 cm lip. Pt remains on AC ventilation RR 10, Peep 10, Vt 500, Fio2 50%. Pt has no a-line but art stick drawn post re-intubation. Oxygenation is good, but there is a continued metabbolic alkalosis that is only partially compensated by Pco2 of 52 on ventilation. Pt is sx for mod amts of thk wht secretions @ times. Given alb/ atrv MDI to abate exp wheezes.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-21 00:00:00.000", "description": "Report", "row_id": 1472167, "text": "Resp. Care Note\nPt followed this shift for Albuterol and Atrovent MDI's Q4. MDI's given inline with ambu. Sxn freq for small amounts of thin white secretions. 40% trache mask in place. Pt off vent for more than 24hrs, vent pulled. Will cont to follow for MDI's as ordered and airway care.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-30 00:00:00.000", "description": "Report", "row_id": 1472073, "text": "1900-0700 rn notes micu\n\n40 y.o with h/o OSA, ETOH abuse, obesity admitted with worsen CHF, EF 40%,that was diagnosed and respiratory failure, found PNA by cxray, chest CT neg for PE. currently intubated and sedated.\n\nneuro: sedated on FEntanyl 125mcg/hr and Versed 7mg/hr, cont halidol IV TID,QTc this shift 0.41. pt response to pain stimul, but does not follow commands, occass opens eyes half way for pain.remains restratined for safety.\n\nresp: intubated on AC 50%/500/RR 12/peep 5, pt does not OBV, sat 97-98%, last ABg 7.41/72/107/47, no changes from previous ABG's. LS coasre, clear to suction, white/yellow thick moderate amount secretion. in morning atempt to chack RSBI failed- pt did not initiate breath.\n\ncv: HR 80's, Afib ( was diagnosed ),rare PVC's, BP 99-110/50-60's, MAP>60, cont LAsix gtt, goal neg 1-2L, currently neg 200cc. morning labs pending.cont Diamox 500mg .CVP 13-15.\n\ngi/gu: foley in place, in the morning notes pink urine possible from slightly puilled during reposition. u/o 80-180c/hr,on LAsix gtt. ABD obese/soft, BS +, no BM this shift, given Colace and SEnna PO.received on TF 45cc/hr, residual 80cc, TF stopped for 4hr nad restart at 30cc/hr.\n\nid: Tmax 100.3, BC A-line from gram pos cocci with pairs and clusters, MD aware, cont Vanco, meropenem.\n\nsocial: full code, no conatct from family this shift.\n\nplan: cont monitoring neuro/resp/cardio status\n monitoring I&o,\n keep MAP>60\n goal to keep neg 1-2l.\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-12 00:00:00.000", "description": "Report", "row_id": 1472130, "text": "resp care\nremains with #7.0 air cuff tube in place, weaning slowly on psv, peep left at 10 due to body habitus. vt's low 300's, occas.dips to mid 200's with increased rr..no evidence of and denies sob..self limiting tachypnea,restlessness. sxning mostly white thin to frothy secretions..good cough. bs rhonchorous t/out. admin mdi's per . refer to flow sheet for further info.. c/w slow wean.\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-13 00:00:00.000", "description": "Report", "row_id": 1472131, "text": "Resp Care\nPt remains on vent. Pt rr in the 40s, placed on A/C overnight to rest. Mdis given. Suctioned for mod amt of thick yellow secretions. Plan to switch back to cpap in morning. Will contnue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-13 00:00:00.000", "description": "Report", "row_id": 1472132, "text": "MICU Nursing Note 1900-0700\nEvents: Pt with increased agitation during evening following visit with family, combative , diaphoretic with HR/BP/RR all increased, no effect from bolus of fentanyl and versed, required Ativan 2 mg IV x 2 doses and increase in con't sedation gtts overnight with good effect.\nDid not tolerate CPAP+PS with poor TV and decreased Sats with RR 40's even with sedation---placed back on AC to rest overnight and to return to CPAP+PS this am. Continues to run temps. Diuresed with lasix overnight.\n\nNeuro: Alert, period with increased agitation following visit from family during evening with pt attempting to get OOB, combative with care, no effect from calm approach, bolused with both fentanyl and versed with no effect, pushing staff away, kicking with right leg, medicated with Ativan 2 mg. IV x 2 with good effect and IV Fentanyl increased to 100mcgs/hr and IV versed increased to 6 mg/hr. Currently IV versed weaned back to 5 mg/hr. Bilat soft wrist restraints to prevent pt from pulling at lines and tubes, Follows commands, attempting to communicate by mouthing words, answers simple questions with head nods.\n\nCardiac: HR= 68-130's Afib with occasional PVC's noted, BP= 120-170/50-70. CVP= 13-17, right SC TLC site C/D/I and all ports patent.\n\nResp: Lungs coarse throughout and diminished at bilat bases, occasional exp wheeze noted, Trach site C/D/I, Occasional small cuff leak noted, trach suctioned for mod. amts. thick white sputum, Initially pt on CPAP+PS at 40 % with RR= 40-48 and TV 200-250's. Sats 94-95% and pt working hard on vent with no change is symptoms after sedation---pt placed back on AC 500-40%-12 with Peep= 10 to rest overnight with RR= 13-20 and MV= with TV= 450-500. Sats improved to 98-100% and pt more comfortable. Will attempt to wean vent back to CPAP+PS this am. Diuresed with 40 mg. IV Lasix and pt neg. 500ml.\n\nGI: Abd obese and soft with + distant bowel sounds all quads, no BM, PEG site C/D/I and patent. Tolerating FS Pulmonary Nutren with beneprotein tube feedings at goal of 45ml/hr with resids. 10ml.\n\nGU: Foley to CD draining clear yellow urine 30-35ml/hr. Pt with small amt rubra menses.\n\nSkin: remains on bari-air bed. skin grossly intact.\n\nID: Febrile with Tmax.=101.5. MICU team aware and following. WBC= 9.4. Continues on IV Flagyl for ? C. diff. Received 650mg. Tylenol with fair effect.\n\nSocial: Pt's daughters in to visit during evening hours. Updated on pt's condition and plan of care.\n\nPlan: ? if need ID consult to eval possible source of temps, ? if need echo for eval cardiac function and CHF, Continue aggressive pulmonary toiletting, Obtain psych. consult to assist with agitation and ? of withdrawal, Wean sedation slowly as tolerated, Wean vent slowly as tolerated, Diurese as needed, Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-13 00:00:00.000", "description": "Report", "row_id": 1472133, "text": "resp care\nreceived on ac mode, converted to psv mode when up to chair..tolerated very well on ps 18. however in afternoon pt pulled out the inner cannula to the ..readvanced to 11 mark, position confirmed by bronchoscopy with pulmonary/thoracics present.placed back on ac due to these events. thick white/slight yellow tinged sputum in small amts. strong cough effort. bronchodilators given q4h. refer to flow sheet for further info.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-22 00:00:00.000", "description": "Report", "row_id": 1472168, "text": "Nursing Note: 1900-0700\nNo significant events for time noted.\n\nNEURO: /following commands; attempting to make needs known by mouthing words. Restless at times with decreased safety awareness requiring bilat soft wrist restraints to maintain integrity of lines. C/O abdominal discomfort; received Tylenol with effect. Gag/cough intact.\n\nRESP: Remains on trach mask at 40% hum. O2 maintaining sats mid to high 90s. LS coarse with some wheezes; receiving MDIs. RR 20s-30s. Strong cough expectorating thick, wht sputum.\n\nC/V: HR 80s-90s afib/aflutter with occasional episode of bradycardia to high 50s; receiving sched dosing of Captopril and Lopressor. SBP 120s. Hct 38. INR 2.7 with goal of .\n\nGI/GU: TF at goal rate 45cc/hr via PEG. U/O 30-50cc/hr and unchanged from previous shift. Med, liquid stool X 1.\n\nID: Afebrile; covered with Cefepime and Vanco. WBC 15 up from 12.\n\nDISPO/PLAN: Full code; speech and swallow for passey muir valve today; no contact from family overnight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-22 00:00:00.000", "description": "Report", "row_id": 1472169, "text": "Resp: pt on 40% t/c with humification. BS are coarse bilaerally. suctioned for moderate amounts of thick yellow secretions. MDI's adminstered Q4 hrs alb/atr with no adverse reactions. Pt has #7 secured @ 12 flange. No distress noted 02 sats @ 98%. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-22 00:00:00.000", "description": "Report", "row_id": 1472170, "text": "Resp. care Note\nPt follwed this shift for Albuterol and Atrovent MDI's as ordered in-line with ambu. #7 in place, cuff deflated. 40% aerosol in use. Strong cough, sxn for thin white secretions, decreased amount form yesterday. restless in bed, freq pulls O2 off but maintains sats 94-95% on room air. Cont to follow for MDI's and airway care.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-22 00:00:00.000", "description": "Report", "row_id": 1472171, "text": "MICU Nurse Progress note 0700-1900\nEvents: pt remains on t collar 40% with cuff deflated, tol well 02 sats 94-100%. OOB-Chair x 3hours, pt att to get out of the chair and was able to stand pivot back to bed w/ mod a x2. remains off IV sedation, sched ativan discontinued with no need for prn ativan this shift.\n\nROS:\n\nNeuro: awake and with periods of anxiety noted, remains restrained for safety, on seroquel with good effect. PEARLS, all ext. strong and equal.\n\nPulm: t-mask 40% 02 sats 96-100% cuff deflated, speech eval pending for PMV trials. LS remain coarse bilat with dim bases. strong cough with sm- mod amt thin white secretions.\n\ncardiac: remains in a-fib/flutter, rate 70's-80's B/P 130's-150's/ 84-106. coumadin decreased to 2,5mg, INR this am 2.7\n\nGI: TF at goal rate of 45ml/hr tol well, abd obese, soft, and nontender normal BS x 4 quads. large liq stool x1 this shift, Lactulose discontinued.\n\nGU: foley patent draining clear yellow urine with sediment, UOP 20-60ml/hr.\n\nID: on day of Vanco/ Cefepime for treatment of ?PNA. WBC 15.1\n\nPlan:\ncontinue close monitoring of 02 sats for tol. of t-mask.\ncontinue to monitor for s/s of anxiety, give ativan as needed.\ndischarge to LTAC facility when bed available.\n\nGU:\n" }, { "category": "Nursing/other", "chartdate": "2184-06-13 00:00:00.000", "description": "Report", "row_id": 1472134, "text": "Nursing progress notes\nEvents: pt up oob x 3 1/2 hrs. this afternoon this rn found pt trach out to #5 instead of #11. micu team, anesthesia, thoracic sx called and at bedside. placed at #11 by using obturator. pt bronched for confirmation of placement. Pcxr done as well. during event pt sats remained 100%.\n\nNeuro: pt alert oriented to self and place and month. follows commands. communicates by mouthing words. She becomes angry when talking about her family. emotional support given and frequently reminded what her plan of care is to help her understand. fentanyl decreased to 75mcq/hr and versed gtt 4mg/hr. pt received ativan 2mg via peg at 0800 and 1800 for anxiety and to help wean iv gtt sedation.\n\nREsp: events as stated above. pt has trach at 11, #7. ls coarse w/ diminished bases. on vent settings cpap/ps on 40% rr 20-30 tv 350.\n\ncv: tele afib 70-90s sbp 120-150. cvp 10-19 lasix 60mg ivp given this afternoon to have pt neg 500cc or even. pt is -300cc since midnight.\nk+ 3.6 this am repleted w/ 40meq kcl via peg. hrt sounds s1s2\n\ngi: abd obese. tube feeding at goal w/ little residual.\n\ngu: foley draining yellow urine w/ a slight drop in uop before lasix to 25cc/hr.\n\nskin: intact. tlcl site redened micu team aware. possible plan for picc when afebrile.\n\nid: pt had temp spike this am to 102.9 team aware bc done. cont on flagyl x 1 more day. plan to do thorocentesis search via us this afternoon to send cx to cytology. Awaiting team to preform us.\n if pt cont to spike team will consult id.\n\nsocial: no family contact this shift.\n\ncode: full\n\nPlan:\nus this evening for thorocentesis search.\npossible ct in am of chest\nid consult in am if she cont. to spike/\nwill need to remove tlcl and place picc once afebrile\ngive ativan prn to help wean sedation.\nawaiting results of cx.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-14 00:00:00.000", "description": "Report", "row_id": 1472135, "text": "Micu Nursing Note 1900-0700\nEvents: Pt with comfortable evening, Fentanyl and Versed gtts continue but not increased during the night, Agitation and Anxiety episode during night with HR up to 150-160's RAF and BP 180-190's/90's ---required IV Lopressor, IV Ativan, and bolus doses of IV Versed and IV Fentanyl---vent changed to AC mode during event as pt tachypneic and not pulling tidal volumes.\n\nNeuro: Resting comfortably most of night, easily arouseable but went back to sleep after stimulation, following commands, IV Fentanyl at 75 mcgs/hr and IV Versed at 4 mg/hr. Awoke at 3:30 am restless/agitated/tachypneic/tachycardic/hypertensive-received bolus doses of IV versed and IV Fentanyl with little effect, received IV Ativan 2 mg. x 2 doses with good effect. Bilat soft wrist restraints to prevent pt from pulling at tubes and line---will attempt to pull at things if unrestrained.\n\nCardiac: HR= 50-80's Afib with freq. PVC's and BP= 102-156/50-60's most of night, during anxiety episode pt with HR RAF 150-160's and sBP 180-190's---received IV Lopressor 5 mg x 1 with rate decreased to 120-130's, received second dose of IV Lopressor 5 mg. x 1 with rate down to 90-110's. CVP= 16-18---no Lasix overnight. Right SC TLC site slightly reddened, all ports patent.\n\nResp: Remains intubated with #7 trach at #11, bilat breath sounds coarse and diminished at bases, bronchospastic following suctioning of trach, trach site draining small amts serous drainage--care done,suctioned trach for mod amts thick white sputum and at times frothy, tolerated CPAP+PS at 40% with PS=18 and Peep=10 with RR= 18-30 and Sats 96-100 with TV 300-350. Placed back on AC 450-40%-14 with peep=10 for resp distress during anxiety episode as pt not tolerating and RR increased to 40-50 with TV= 200's. Will attempt to return to CPAP+PS by am. No U/S last eve to mark and locate area for potential thoracentesis for pathology.\n\nGI: Abd obese with + hypoactive bowel sounds all quads, no BM, PEG site C/D/I and patent, tolerating FS Pulmonary Nutren with Beneprotein at 45ml/hr with resids= 5 ml.\n\nGU: Foley to CD draining clear yellow urine 25-45ml/hr. Pt I/O was even at MN and is positive 500ml since MN with LOS positive 2.8L.\n\nID: Continues to spike temps with Tmax- 100.1 overnight. WBC= 12.6. continues on IV Flagyl, Await ID consult.\n\nSkin: Remains on bari-air bed, skin grossly intact.\n\nSocial: No contact from family or friends overnight.\n\nPlan: U/S today with possible thoracentesis to send spec. off for pathology, Possible chest CT today, Await ID consult in regards to continued temp spikes and neg. cultures to date, ? if need to obtain echo to eval cardiac function on CHF issues, Continue aggressive pulmonary toiletting, Await psych consult for suggestions to manage pt's agitation while decreasing continuous IV sedation, monitor temps, support pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-03 00:00:00.000", "description": "Report", "row_id": 1472092, "text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nREMAINS ON PS NOW 15/15 .50. ABG STABLE. SX FOR\nWHITE. WILL C/W PS AS TOLERATED W/ PEEP NOW 15.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-08 00:00:00.000", "description": "Report", "row_id": 1472111, "text": "MICU Nursing Note 1900-0700\nEvents: Pt remains sedated on Fentanyl and Versed gtts, Diuresed with IV Lasix con't gtt and received 1 time dose of IV chlorothiazide with good effect. No vent changes overnight.\n\nNeuro: Opens eyes and follows commands inconsistently, makes eye contact and attempts to talk around tube with stimulation, Occasional attempts to sit up and get OOB, attempts to grab at tubes, bilat soft wrist restraints, IV Fentanyl gtt infusing at 125 mcgs/hr and IV Versed gtt infusing at 6 mg/hr, pt occasionally requires bolus doses of each during increased activity.\n\nCardiac: HR= 60-70's Afib with occasional PVC's, BP = 100-120's/60's, Left SC TLC site C/D/I and all ports patent, IV Lasix infusing at 14mg/hr. Received 1 time dose of clorothiazide with good effect.\n\nResp: Remains intubated and no vent changes overnight, Current vent settings include: 500-50-AC12 with Peep=10. Overbreathing vent by 1-10 breaths, Sats= 95-98%, MV= , Lungs coarse throughout, ETtube suctioned for mod. amts thick white, oral suction for same., ABG= 7.46-58-88.\n\nGI: OGtube placement checked by auscultation, Tolerating tube feedings FS :Pulmonary Nutren with beneprotein at 45 ml/hr with residuals of 10ml, Abd obese with distant + bowel sounds, Continues with loose golden stools---mushroom catheter intact and patent.\n\nGU: Foley to CD draining clear yellow urine > 100ml/hr. Pt neg. 350- ml at midnight and neg. > 1 liter since MN after receiving cholorothiazide dose.\n\nID: Tmax= 100.5, WBC= 9, continues on IV vanco and IV meropenum.\n\nSkin: on bari-air bed, grossly intact.\n\nSocial: No contact from family or friends during night.\n\nPlan: Continue aggressive diuresis, con't pulmonary toiletting, Await plan of possible trach either by surgery or in IR, Attempt to wean both vent and sedation as tolerated, Support pt and family .\n" }, { "category": "Nursing/other", "chartdate": "2184-06-08 00:00:00.000", "description": "Report", "row_id": 1472112, "text": "Resp Care: Pt continues intubated #7.5 oett secured @ 23 @ lip and on ventilatory support with a/c, no vent changes overnoc maintaining hypercarbia with relative resp alkalosis, acceptable oxygenation on +10 peep; bs diminished bilat, sxn thick white secretions, rx with mdi albuterol/atrovent, not done d/t peep level, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-20 00:00:00.000", "description": "Report", "row_id": 1472163, "text": "Resp Care\nPt remains trached with #7.0 . This am pt partially pulled out trach sats remained >97% and pt was in no distress, trach was advanced in to 12 @ stoma. vent settinged weaned throughout the day and pt was placed on 50% TM this afternoon. BLBS diminished, pt suctioned for thick white secretions, pt also has strong productive cough off the vent. RR off vent 25-35 though pt is in no distress sats >97% HR 70-90. Plan to remain of vnet as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-21 00:00:00.000", "description": "Report", "row_id": 1472164, "text": "Resp Care Note:\n\nPt cont trached on cool mist aerosol as per Carevue. Lung sounds coarse dim @ bases suct sm=>mod th pale yellow sput. Pt tol trach mask overnoc ABG ess same as when pt was ventilated using A/C. MDI given as per order. Cont trach mask as tol; vigorous pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-04 00:00:00.000", "description": "Report", "row_id": 1472093, "text": "Nursing progress notes 1900-0700\nNeuro: Pt arousable to voice, opening eyes spontaneously, MAE with good stringth. PERRL, sedated on Versed 4mg/hr and Fentanyl 125 mcg/hr. Following commands inconsistently. attempting to talk through ETT. Pt was very much agitated early in the shift, pulled out the OGT accidently by the Pt, pt became quiet with boluses and increase in sedation. Pt denies pain.\n\nResp: Received on vent CPAP+ PS, 15/+15, fio2 50%, cont same settings now. RR in 20's. LS clear upper lobes and diminished bases. Sxn frequently for moderate thick yellow secretion via ETT and white secretion orally. ABG 7.38/66/84, team notified.\n\nCV: HR 73-94, A-fib/A-flutter with occasional PVC's. Heparin drip restarted units/hr at 2100 hrs and titrated to 1300 units/hr.PTT 71, same dose contd. Lasix drip 9 mg/hr. Pt is diuresing.\n\nGI/GU: Abd very obese, +BS, no BM THIS shift, bowel regimn continued. Lactulose TID started. TF 45ml/hr, residual 10-30ml/hr. Foley patent, drained out 100-500 ml/hr,yellow clear urine.\n\nID: T max 100.2, cont on antibiotics (Vanco/Meropenem).\n\nSocial: No contacts from family tonight.\n\nPlan: Family meeting today\n Cont pulm toilet\n wean vent as tolerated\n sedation as needed for comfort/safety\n monitor PTT.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-04 00:00:00.000", "description": "Report", "row_id": 1472094, "text": "Resp Care: Pt continues intubated #7.5 oett secured @ 23 @ lip and on ventilatory support with 15/15/.5 maintaining Vt 300's with Ve ~7 L, acceptable oxygenation with compensated hypercarbia; bs diminished, sxn thick tan secretions, rx with mdi albuterol/atrovent, not done d/t peep level, will cont support.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-04 00:00:00.000", "description": "Report", "row_id": 1472095, "text": "7A-7PM Nsg Progress Note\nRESP: Pt remains intubated and vented on CPAP 50% 15 Peep, 15 pressure support, O2 sats 96% Peep and pressure support decreased to 10. repeat ABG~ 82/69/7.40 rr32-40, TV's 200, MV 7 liters, 170. pt suctioned q 4 hrs for sticky white secretions. mouth care done q 4 hrs. tape changed - ETT @ 23 cm.\n\nCV/FLUIDS: bp 90-100/60 HR 80's afib with occ aflutter/PVC CVP~14-15 goal<12 continues on Lasix gtt at 10 mg/hr (increased from 9 mg/hr) pt is currently even. Uo 50-100 cc/hr. Pt remains on IV Heparin gtt @ 1300 units/hr\n\nGU: urine cloudy yellow changed to bloody. UA, and urine cx sent. repeat PT/PTT sent ~ pending.\n\nGI: tube feeds (FS Nutren Pulm @ 45 cc/hr at goal), minimal aspirates. +bowel sounds, no stool. (had large bm on nights) give bowel meds prn.\n\nNEURO: pt adequately sedated on Fentanyl @ 125 mcg/hr, Versed 4 mg/hr\nhands restrained for safety (pt will pull ETT out). easily arousable, nods head appropriately, spont movemnts to all extremities.\nagitated at times, prn boluses of Fentanyl/Versed.\n\nID: low grade temp 100.4 WBC 11.6 pt remains on Vanco and Meropenem urine cx sent. A-line and Left subclavian dsg changed - sites look clean, no reddness.\n\nSOCIAL: mom called to check on pt. intern to call her back with update. pt is full code.\n\nPLAN: ?trach/peg soon. continue with pulmonary toileting, wean vent as tolerated, continue to diurese, goal CVP<12, monitor for bump in creat., sedation for comfort, continue antibx for sinusitis/pneumonia. continue Heparin gtt (follow PTT)\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-21 00:00:00.000", "description": "Report", "row_id": 1472165, "text": "Nursing progress notes 1900-0700\nReview carevue for all additional data\n\nEvents: no significant events, tolerated trach mask overnight.\n\nNeuro: lightly with fentanyl 50mcg/hr and versed 2mg/hr gtt, and po lorazepam and started seroquel po from yesterday. patient less agitated, but times wants to come out of bed and put legs out of bed and asking for mother to come and was almost in tears. following commands and MAE with 4 point restraints are in place for safety.\n\nCv: A fib,Hr 70-90's with occasional ectopy, Sbp 100-120 and continued po captopril and lopressor.\n\nResp: tolerated trach mask overnight and continued 40% cool mist aerosol. bilateral lung sounds coarse and diminished at the base. Large thick yellow secreation with suction. RR 30-36 and o2 sats 95-98%.\n\nGi/GU: tolerating TF with goal 45 ml/hr and abd obese, BS present small loose stool. Iv lasix 40 mg given with good effect.\n\nSkin: intact\nId: afebrile continued on vanco and cefepime.\nSocial: no calls from family.\n\nPlan: continue trach mask as tolerated\n oob to chair\n ? PiCC line placement if less agitated\n wean sedation as tolerated\n emotional support to patient\n" }, { "category": "Nursing/other", "chartdate": "2184-06-21 00:00:00.000", "description": "Report", "row_id": 1472166, "text": "7AM-7PM()\n\nON FULL CODE\n\nNO SIGNIFICANT EVENTS.\n\nCVS:HR 65-88 A-FIB NIBP 97-130/57-78 ON CAPTOPRIL LOPRESOR ASPIRIN AND WARFARIN(PO).WARFARIN DOSE CHANGAGED TO 5MG/HS TODAY.HAS LSC ALL 3 PORTS ARE PATENT.\n\nNUERO;RECIEVED THIS AM WITH INJ FENTANYL 3 MCG/HR AND VERSED 1MG SEDATION SCORE WAS 3 AND COULD STOP SEDATION BY AFTERNOON AND NOT AGITATED AFTER STOPPING IT.RESTRAINTS ARE OFF NOW.\n\n\nRESP;REMAINS ON TRACH MASK FIO2 50% NO CHANGES ARE MADE SINCE AM RR 25-35 RESP EFFORTS ARE NORMAL SPO2 98-100. SUCTIONED FREQUENTLY FOR COPIOUS AMOUNTS OF THICK YELLOW SECRETIONS.\n\n\nGI/GU;ABD SOFT BS + ON TF @ GOAL BOWEL NOT OPENED AT THIS SHIFT.\nVOIDING VIA FOLEYS 30 ML/HR.\n\nSKIN REMAINS INTACT,WARM AND DRY.OOB TO CHAIR 4 HRS AND TOLERATED WELL.\n\nID;ON ANTIBIOTICS.\n\nNO VISITORS OR CALLS UPTO THIS TIME.\n\nPLAN;TO KEEP HER ON CPAP OVERNIGHT TO REST.PMV TO TRY LATER ON.GOAL IS TO KEEP SEDATIONS OFF AND TO KEEP HER COMFORTABLE WITH PRN DOSE OF SEDATION.SPEECH AND SWALLOW FOR TOMORROW.PICC LINE INSERTION WHEN PT IS MORE STABLE.MONITOR VITAL SIGNS AND FREQUENT SXN TO CLEAR. SECRETION.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-17 00:00:00.000", "description": "Report", "row_id": 1472147, "text": "Nursing progress notes 1900-0700\nReview carevue for all additional data\n\nAllergy: pcn and morphine\nCode: full\n\nevents: Temp spikes to 102.8, pan cultured, good effect to tylenol and cool bath, tem down to 99.4. Started antibiotics vancomycin and cefepime. sedation has been weaned down to assess patient's tolerance to off sedation.\n\nNeuro: with versed 4mg/hr and fentanyl 75mcg/hr and plans to wean versed down to 3mg/hr and fentanyl to 50mcg/hr. Alert and opening eyes spontaneously and mouthing words to communicate. Following commands inconstistently. Bilateral wrist restraints are in place for safety.\n\nResp: Lightly , and continued on CPAP+PS 20 and peep 10 and 40% o2, rr 24-36 and o2 sats 95-100%. Bilateral lung sounds coarse and diminished at the base, with copious whitish to yellow thick secreation.\n\nCv: A fib with rare ectopy, SBP 110-140's and continued po lopressor and captopril. Free water bolus continued for high Na. Am labs Na 143 and K 3.9, need to check K later as patient received lasix.\n\nGu/GI\" tolerating TF with goal 45 ml/hr with minimal residual via PEG tube, abd obese and BS present, no BM this shift and continued regular laxativess. UO 30-200ml/hr and lasix 40 mg given, set goal to keep 1L negative balance.\n\nSkin: intact\nID: t max 102.8, started on vancomycin and cefepime.\n\nPlan: Close monitoring for withdrawal from sedation.\n Monitor temp curve and F/U culture\n F/U results of ct torso\n Goal fluid balance to negative 1L and diuresis\n Monitor lytes and replete as needed\n" }, { "category": "Nursing/other", "chartdate": "2184-06-17 00:00:00.000", "description": "Report", "row_id": 1472148, "text": "respiratory care\npt remains trached,no vent changes made this shift. BS coarse, diminished at bases.Suctioned for small amt of yellow thk secretions.\nPT tachypnic at times.\nPlan:MOnitor resp status closely.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-17 00:00:00.000", "description": "Report", "row_id": 1472149, "text": "Respiratory care\nPt remains on PSV/cpap, able to wean PSV to 16cm. Pt recieved mdi's as ordered Suctioned for large amts of white secrections. Plan to continue to wean PSV/Cpap as tol.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-03 00:00:00.000", "description": "Report", "row_id": 1472090, "text": "Nursing progress notes 1900-0700\nCode: Full\nAllergies: PCN, Morphine.\n\nPt is 40 y/o female with h/o OSA, ETOH abuse, obesity, admitted to MICU with worsening CHF (EF 40%) and resp failure. CXR revealed PNA, chest CT negative for PE. Pt is currently intubated and sedated.\n\nNeuro: Sedated on Fentanyl and Versed. Easily arousable, able to follow commands inconsistently, giving mouthwords, asking for suctioning and turning. Spontaneous purposeful movement to all extremities. Agitated at times, sedated with PRN boluses with good effect. Denies pain.\n\nResp: Received intubated on vent CPAP+PS 20/+5, fio2 50% . Sat 96-99%, LS coarse all over, sxn moderate thick yellowish secretion via ETT and oral suction less frequently. Vent settings changed to A/C mode 500/12/+5/50%.\n\nCV: HR 76-88, A-fib, with occasional PVC's and atrial flutter. SBP 95-122, MAP >60, CVP 13-17(goal is < 12). Pt cont on Lasix drip 5 mg/hr. Pt has rt radial A-line with good waveform. Lt SC TLC for access.\n\nGI/GU: Abd obese, + BS, no BM this shift, TF 45 ml/hr with residual 20-30 ml/hr. OG tube patent placement checked. Foley draining yellow clear urine 60-140 ml/hr. Goal 1-1.5 lit negative.\n\nID: Temp 99.2-99.6, cont on abt therapy.\n\nSocial: No calls from family tonight.\n\nPlan:\n\nPulmonary toileting\nWean vent as tolerated\ncont duresis, goal of CVP <12\nsedation for comfort and safety\nroutine ICU care and monitoring\nemotional support to the Pt and family.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-03 00:00:00.000", "description": "Report", "row_id": 1472091, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: PCN, morphine\n\nNeuro: Pt arousable to voice on Fentanyl 125mcg/hr and Versed 3.5mg/hr. Following commands inconsistently, purposeful movement of extremities, attempting to talk through ETT, cooperative with care. Appearing much more comfortable and less restless than yesterday. Pt denies pain.\n\nCV: HR AFIB/a-flutter 76-105 with occasional PVC, ABP 97-123/57-75, CVP 10-16 (goal <12), both with good waveform. Heparin drip started for AFIB, PTT due at 1730, will titrate drip according to results. Lasix drip increased to 9mg/hr per team request as pt is positive .5L since midnight, also ordered for one time dose Diuril. Per rounds, continue diuresis until creatinine bumps.\n\nResp: Pt switched to CPAP+PS this AM, vent settings altered due to pt becoming tachypneic and dropping sat. Current settings CPAP+PS 50%/+15/PS15 with ABG of 7.34/76/99. RR in 20's with sats >94%, STV ~200-300, MV . Lung sounds clear to coarse to diminished. Suctioned frequently for moderate amounts of thick, white secretions. Sputum sample sent, results pending.\n\nGI/GU: BS x 4, no stool this shift. Ordered for Lactulose TID to faciliate BM. TF running at goal of 45cc/hr with fluctulating residuals (0-80cc). Foley patent and draining moderate amounts cloudy, yellow urine. UO 45-120cc/hr. Pt is + .5L for since midnight. AM K repleted.\n\nID: Tmax 99.6 PO, continues to receive ABX (Vanco/Meropenum) for PNA, sinusitis. Most recent blood cultures pending.\n\nSocial: No contact from family this shift.\n\nPlan:\naggressive diuresis, monitor UO\npulmonary toileting\nsedation as needed for comfort/safety\nsuppository/enema if no results with lactulose\nfollow up culture data\nroutine ICU care and monitoring\nsupport to pt and family\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-07 00:00:00.000", "description": "Report", "row_id": 1472107, "text": "resp care\nPt remains on a/c 500x10 50% 10 peep with peak/plat 32/24. BS coarse bil with scattered insp wheeze.Suct for sml amts of thin white sput.Alb/atro mdi given with some clearing of wheeze. Occ episodes of tachypnea that resolve with sedation. held due to peep level.Will cont to follow with psv trials during the day.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-07 00:00:00.000", "description": "Report", "row_id": 1472108, "text": "npn 23:30-07:00 (please also see carevue flow notes);\n\nStarted on Lasix gtt approx 16:00 to assist diuresis, received pt on 10 mg/hr at 23:30, urine output approx 100 mls per hour; per MR, read goal for diuresis as \"1000-\" mls per 24 hrs; seemed wide parameter for goal, checked w/ covering resident, who stated goal of approx 100 mls per hour, however this goal would not provide diuresis of even 1000 mls per day; MD adjusted order to increase range of Lasix to 15 mg/hr, and stated diuresis goal at approx 100 ml/hr;\n also double checked w/ resident re ordered free water boluses of 100 mls q 4 hrs, resident MD confirmed this order;\n\nPt aggitated/bothered frequently this night, increased on sedation from versed at 6 mg/hr to 7; and fentanyl from 125 mcg/hr to 135 mcg/hr; pt also found to have large amount brown non-formed almost liquid stool--pt on stool softeners, and stimulants; pt cleaned, mushroom cath inserted w/ K-jelly; pt more restful after having been cleaned of stool; mushroom cath inserted;\n auto-turn of bed also turned off from 3a-6a, to assist pt's rest and participation in remainder of lessons;\n\nPt in a-fib, not on hep gtt d/t hematuria; v-response was in mid 50's at approx 12a, v-response gradually increased during the night, lopressor has been held for the past couple days for low hrt rate; given this a.m.;\n\nPt remains on Abx for sinusitis;\n\nPt w/ met alkalosis felt d/t chronic resp acidosis, from restrictive lung dz of obesity; pt admitted w/ chf/pleural effusions/a-fib; receiving prn electolyte repletion;\n\nPt also has 2 daughters, one still school age, one approx 19 or 20 years old; social service c/s entered d/t oldest daughters statements which seem to show her limited understanding of her mothers illness;\n\nPLAN:\n1) pt likely w/ be trached/PE'd and go to rehab before home\n2) ? attempt some wean of sedation?\n3) electrolyte repletion prn\n4) social services aware of family--requested them to see daughters\n5) tube feeds at goal\n6) assess intravascular fluid status re lasix gtt\n7) bowel regime\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-07 00:00:00.000", "description": "Report", "row_id": 1472109, "text": "NPN-MICU\nMs has made some progress in her diuresis today.\n\nNeuro:pt cont on Fentanyl and versed 125mcg/6mg respectively. She has needed and occas bolus to keep her in the bed as she wanted to get out to go to the BR. She is much calmer after her haldol dose. She cont to be able to MAE and PERL.\n\nResp/GU:Pt has cont to be aggressively but gently diuresed with IV lasix, 12mg/h has u/o 100-200cc/hr and she is currently 250cc neg. The goal is about 50cc neg for day. There have been no vent changes for today. She will be eval for Trach by IP vs Surgery, no date yet. She cont to have min amts of white sputum.\n\nCV:She cont on AF, BP 100-118/60's. K= was replaced and will be rechecked at 4pm. She will cont on lopressor and prob start ACE inhibitor tomorrow. Will still hold anticoag for now\n\nGI: pt cont on TF at 45cc/hr Pulmonary mix. She has no asp but contt o passed liq stool, mushroom cath in place. NA++ is improed but will cont on free water boluses forn now. HCt and coags are stable\n\nID:pt cont with low grade fever, given tylenol, still neg cx. She will complete a 14 day course.\n\nSocial:House staff spoke with pt's mother over the phone and she has consented for the Trach and PEG, they were updated at that time.\n\nA/P:Will cont with aggressive diuresis, goal of 500-1000cc neg, follow lytes and replace as needed,Cont with aggressive pulm toilet and follow O2 sats and labs to eval gas exchange. Awaiting an A-line.\n Cont to asses tol of TF, note stool amt\n Cont sedation as needed\n Follow fever curve and await cx results.\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-07 00:00:00.000", "description": "Report", "row_id": 1472110, "text": "RESPIRATORY CARE: PT REMAINS W/ A 7.5 ORAL ETT IN PLACE.\nREMAINS ON THE AC MODE AS PER CV. CVBG STABLE. LASIX WAS\nRESTARTED. SX FOR WHITE SPUTUM. ALBUTEROL/ ATROVENT MDI'S\nGIVEN. TRACH BEING D/W FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-20 00:00:00.000", "description": "Report", "row_id": 1472160, "text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th pale yellow sput, MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-16 00:00:00.000", "description": "Report", "row_id": 1472143, "text": "Nursing progress note (1900-0700):\n40 yo female w/ obesity, CHF, Afib, fevers.\n\nEvents: Temp spike to 103.0. Given po tyelenol and placed on cooling blanket w/ + effect. Team aware..no cultures ordered. Temp currently 100.1.\n\nROS:\n\nNeuro: Pt remains on versed/fent of 4.0/75.0, opening eyes spontaneously, unable to assess orientation as pt is trach/vented. Follows commands inconsistently.\n\nResp: Pt remains vented and trached. Currently on AC of 40%/400x10/10+. VBG 7.39/57/42/36. MV 6.0-7.0, TVs 300-400. Breathing 10-13 breaths over vent. Infreq sxn'd for thick/white sputum.\n\nCV: BP 95-1 teens/50s, HR 70-80s. Rare PVCs. Afib. Captopril dose increased and lopressor increased to TID. 1+ generalized edema. AM labs pending.\n\nGI/GU: Abdomen obese, BS present. No BM this shift. Cont on lactulose. TF @ goal of 45cc/h...small residuals. Urine yellow/clear. UOP marginal at times...20-35cc/h. Team aware...lasix held for now. At this time pt is +400cc since midnight (goal is to be - 1L).\n\nID: febrile to 103.0. Cont on Flagyl. C.diff neg to date (3rd spec sent yest.).\n\nPlan: Retry PSV in attempt to wean vent, ? diurese today, monitor lytes, temps, and labs, f/u cultures.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-16 00:00:00.000", "description": "Report", "row_id": 1472144, "text": "RESP CARE NOTE\nPATIENT REMAINS ON AC. SUCTIONING SMALL TO MODERATE AMOUNTS OF THICK YELLOW SECRETIONS. PT APPEARS AGITATED AT TIMES. ALB/ATR MDI GIVEN Q4\n" }, { "category": "Nursing/other", "chartdate": "2184-06-16 00:00:00.000", "description": "Report", "row_id": 1472145, "text": "focus update note\nplease see flowsheet for details\n\npt t max 101- no panculture today per micu team, flagyl discontinued as no improvement in fever seen while pt on medication, pt given tylenol for fever control.pt to have CT of Torso for fever of unknown orign. cvp 15-22 40 mg iv lasix given at 1400 with good diuresis\n\npt continues in afib heart rate 80-90s, continues on lopressor per ngt, sbp 140/70\n\npain: well controlled with fentanyl\n\nneuro: pt lightly on versed 4 mg/hr- pt alert cooperative today, mental status appears imrpoved based on nursing report, following command consistently, moving all extremities, although pt does become confused asking to go outside and crying because she can not. pt requested that her mother come in today and pt mother visited for a few hours this afternoon.\n\n\nresp: o2sat 95-100%, lung sounds clear dim at bases with occasional wheezes on inspiration and expiration, given inhalers with good effect, ventilator weaned to cpap 40% 10 peep 20 ps 400 x 10, small to moderate amounts yellow thick to thin secreations from ett suctioned q 2-3 hours\n\ngu/gi: lasix today 40 mg iv with good diursis - urine output > 30 cc all day, no bm today bowel sounds present pt given colace, lactulose. tube feedings continue with 200 cc free water bolus' for elevated sodiums- minimal residuals 5-10cc q 4 hours.\n\nplan: Ct torso later this afternoon, continue to provide support to pt as she is anxious and at times confused, wean ventilator as tolerated, keep pt negative 1 liter fluid volume over 24 hours\n" }, { "category": "Nursing/other", "chartdate": "2184-06-16 00:00:00.000", "description": "Report", "row_id": 1472146, "text": "Respiratory care\nPt remains on vent with #7 , pt converted to PSV/Cpap rr ranging from 20-52. Plan to remain on PSV/Cpap overnight. Pt traveled to cat-scan at end of shift without incident.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-06 00:00:00.000", "description": "Report", "row_id": 1472103, "text": "Resp Care: Pt continues intubated #7.5 oett secured @ 24 @ lip and on ventilatory support with psv, increased to 15/10 for overnoc rest ~ midnoc maintaining Vt 2-300, Ve ~6-8 L, spo2 95-100%; bs diminished, sxn thick white secretions, rx with mdi albuterol/atrovent, held d/t peep level, will cont slow wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-06 00:00:00.000", "description": "Report", "row_id": 1472104, "text": "RESPIRATORY CARE: PT REMAINS W/ A 7.5 ORAL ETT IN PLACE.\nCHANGED TO PS .50 FROM 15/10 .50 WHICH ARE HER\nRESTING SETTINGS. LUNG COMPLIANCE REMAINS POOR AND\nC/W A STIFF LUNG-CHEST WALL SYSTEM. SX FOR WHITE SPUTUM.\nALBUTEROL AND ATROVENT MDI'S GIVEN. ETT PULLED BACK 1 CM\nPER CXR/MD . WILL C/W PS 10 AS TOLERATED.\nPOSSIBLE TRACH PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-20 00:00:00.000", "description": "Report", "row_id": 1472161, "text": "Nursing progress notes 1900-0700\nwritten at 0446\nReview carevue for all other additional data\nAllergy: PCN and Morphine\ncode: Full\n\nNo significant events overnight\n\nNeuro: Sedation weaned down to versed 2mg/hr and fentanyl 50mcg/hr gtt, and continued po lorazepam and iv haloperidol regular dose. Able to follow simple commands AND MAE, mouthing words to communicate. At times she is agitated and puts leg over the bed and wants to come out of bed, and wants to see her mother, who left home minitues ago and was crying. reassured and good effect with lorazepam and haloperidol. 4 point restraint are in place for safety.\n\n\nResp: Lightly and continued on same vent settings, PSV 20/10 peep. Bilateral lung sounds clear and coarse and diminished at the base. yellow thick secreation suction.\n\n\nCV: a fib, rate controled, continued on po metoprolol and captopril.AM labs pending.\n\nGI/GU: Tolerating TF 45 ml/hr with out residual, BS present, and small BM this shift. Iv lasix 40 mg given and good diuresis.\nSkin: intact\nSocial: mother and daughter visited last night.\n\nPlan: wean sedation and psv as tolerated\n monitor temp curve and cont antibiotics\n oob to chair as tolerated\n Emotional support patient and family\n" }, { "category": "Nursing/other", "chartdate": "2184-06-20 00:00:00.000", "description": "Report", "row_id": 1472162, "text": "MICU Nurse Progress Note 0700-1900\nEvents: pt pulled trach tube partially out, replaced by RT, placement confirmed by CXR at 0800. pt had no SOB, 02 sats 97-100% throughout episode. pt cont to be anxious, started on seroquel MD, Haldol changed to prn, unable to wean fentanyl or versed drips. Vent weaned to PSV 30% 8/5 PEEP. OOB- Chair tol well for 2 hrs then became agitated/ anxious. resolved when back in bed.\n\nNeuro: , following commands except during periods of anxiety/ agitaion. Remains on fentanyl gtt at 50mcg/hr and Versed at 2mg/ hr.PEARLS, all ext mod and equal str.\n\nPulm: trach tube reposiotioned, and vent weaned to current settings of PSV 30% 8/5 PEEP. LS clear bilat with dim bases. denies SOB, breathing is mostly unlabored with periods of tachypnea around anxiety/ agitation. 02 sat 97-100%\n\nCardiac: remains in A-fib HR 70's-90's B/P 110's-130's/ 60's-80's. L CVL patent. pt evaluated for PICC placement, however due to pt agitation IV team was unable to attempt to place PICC.\n\nGI: Abd soft, nontender with normal BS x4 quads, TF at 45ml/hr via PEG tube, tol well. sm loose brown BM noted this shift.\n\nGU: foley cath patent draining clear yellow urine with sm amt sediment. UOP 20-50ml/hr.\n\nID: cont on cefepime and Vanco for tx of PNA. T-max 100.0 po this shift, WBC 12.6.\n\nSocial: no family visit this shift, pt agitated at times, asking to go home, redirected and reinforced to pt with some effect.\n\nPlan: cont vent weaning as tol.\nmonitor effect of seroquel and cont to transition from fentanyl and versed to ativan and seroquel.\nCont on course of IV abx.\nObtain PICC line and remove CVL.\ntransfer to rehab facility when appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-06 00:00:00.000", "description": "Report", "row_id": 1472105, "text": "NURSING PROGRESS NOTES\nREVIEW OF SYSTEMS:\n\nNEURO: PT SEDATED ON VERSED GTT 6MG/HR AND FENTANYL 125MCQ/HR. SHE AWAKENS W/ NAME CALLED AND AT TIMES SHE AWAKENS SPONTANEOUSLY. MAE FOLLOWS COMMANDS\n\nRESP: PT ORALLY INTUBATED AND X 2 THIS SHIFT. SHE IS AT 23CM AT THE LIP LINE PT ON CPAP 15/10 50% CHANGED TO CPAP HOWEVER SHE BECAME TACYPNEIAC 40S, LS I/E WHEEZES MDI GIVEN, AFTER A FEW VENT CHANGES SHE ULTIMATELY IS ON AC 12/500/50% 10 PEEP. SHE IS RESTING COMFORTABLY AT PRESENT\n\nCV: TELE AFIB 70S SBP 95-110S HRT SOUNDS S1S2 PT POS 900CC OVER 24HRS LASIX GTT RESTARTED AT 1600 FOR GOAL OF NEG 1-2 LITERS CVP 18-20\nK+ 3.8 REPLETED W/ 40MEQ KCL VIA NGT. REDRAW LYTES AT AND REPLETE.\n\nGI: BS + ABD OBESE NO STOOL THIS SHIFT SHE IS ON A BOWEL REGIMENT. TUBE FEEDINGS AT GOAL RESIDUALS 10CC.\n\nGU: FOLEY DRAINING YELLOW URINE. 20-60CC/HR\n\nID: URINE CX NEG, SPUTUM C/S NEG. BC PENDING. PT ON VANCO AND MEREPENEM.\nTMAX 100.7 TYLENOL GIVEN\n\nCODE: FULL\n\nSOCIAL: DAUGHTERS IN TO VISIT AND HER DAUGHTER REQUESTED TO TAKE PINK BELONGINGS SLIP AND HER MOTHERS WATCH AND , PINKS SLIP GIVEN TO .\n\nPLAN:\n\nCONT LASIX GTT TITRATE TO NEG 1-2 LITERS\nREDRAW LYTES AT \nTRACH AND PEG SOMETIME THIS WEEK\nCONT TO KEEP PT COMFORTABLE W/ SEDATION\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-07 00:00:00.000", "description": "Report", "row_id": 1472106, "text": "NSG 1900-0000\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\nPT REMAINS SEDATED ON FENT 125MCG/VERSED 6MG. ALERT/FOLLOWS COMMANDS WHEN SEDATION OFF. MAE. SOFT RESTRAINTS ON.\n\nHEART RYTHM AFIB WITH NO ECTOPY. HR 50S-70S/ SBP:100S/ REMAINS ON LASIX GTT WITH POSITIVE DIURETIC RESPONSE/ UOP 100-120CC/HR/ GOAL NEG 1L.\nLYTES SENT AT / K:4.3, TEAM AWARE.\nLOW GRADE TEMP/TMAX:100.1\n\nREMAINS ON AC/500/50%/15/PEEP 10. LUNG SOUNDS COARSE AND INSP WHEEZES AT BASES/ RECEIVED MDI PER RT. SUCTIONED AT TIMES MODERATE AMOUNT OF THIN WHITE SECRETIONS.\n\nABD SOFT, POS BS. NO BM/ REMAINS ON BOWEL REGIMEN.\n\nFOLEY PATENT DRAINING CLEAR YELLOW URINE.\n\nSKIN W/D/ DIAPHORETIC AT TIME. BATHE/ ON MAXXAIR MATTRESS/ CONT REPOS.\n\nPT'S DAUGHTER CALLED, INQUIRE RE:PT 'S CONDITION AND STATES: \"I NEED YOU TO TELL ME WHEN I CAN COME AND MY MOTHER WOULD BE AWAKE SO I CAN TALK TO HER\" / UPDATE GIVEN. SOCIAL SERVICE TO EVALUATE.\n\nCONT CURRENT POC\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472057, "text": "CCU NSG NOTE: ALT IN RESP\nO: For complete VS see CCU flow sheet.\nID: T-max 100.8 at 8am down to 98.6 at 1600\nRESP: Pt remains intubated with vent settings AC 500 X 16 with rare overbreathing, 5 PEEP. PIPs running in low 30s. She has small to mod white thin secretions. Breathsounds are diminished thruout. If she wakes up at all her sats will drop to the low 90s. Sats decreasing HOB kept above 45 degrees, she is on pnuemoboot and on ppi. Mouth care being given Q 4 and prn.\nHEME: INR 3 and pt received 1mg IV vit K for line placement. As next INR came back 3.1 and he has received 2mg IV vit K. IV was able to place second IV and when consent is signed he'll receive 2u for central line placement. Coumadin is being held.\nCV: Pt remains in afib with HR 70-80s with no ectopy. BP in low 90s early in the shift, but now creeping up to 120s. All cardiac meds held.\nRENAL: U/o varies with blood pressure. As Bp goes up urine output goes up. She is now ~750cc neg for the day and over 2 liters neg LOS. Creatinine conts to decreased to 1.\nGI: NG tube placement varified by Xray. When line is in probalance with start at 40cc/hr and increased to goal of 80cc/hr. She has positive bowel sounds. No BM.\nMS: Pt remains sedated on propofol at 40mic/kilo. She will rouse occasionally and when she does her sats will drop.\nSKIn: Pt has no areas of breakdown. She was changed to barimetric bed and is automatically turned Q 30min.\nSOCIAL: We obtained consent from her mother for and central line placement. Pts 12y old daughter and 20y old daughter live with grandmother.\nA: sedated and intubated.\nP\r: Proceed with central line placement. Monitor blood gases. Cont with position changes per bed. Cont with vap protocol.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472058, "text": "Respiratory Care\nPt remains intubated (#7.5 ETT 23@lip) and on vent support. Vent changes were FiO2 dropped from 50 to 30%. Lung sounds were dim t/o. Suctioned for small amounts of white thin secretions. MDI's given with no adverse effects. Pt has had ABG's x2 that show metabolic alk with resp alk. New ABG sent verify. Care plan is to follow ABG's and continue current therapy.\n\nABG retuned and continued to show resp/meta alk. MD aware. Vent changes were RR dropped from 16 to 12 and FiO2 increased from .3 to .6, ABG will be drawn. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-11 00:00:00.000", "description": "Report", "row_id": 1472123, "text": "Resp Care\nPt recived on vent. S/p trach on previous shift, #7 . Pt suctioned for mod amt of blood-tinged secretions. Mdis given. Abg acceptable, fio2 weaned. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-11 00:00:00.000", "description": "Report", "row_id": 1472124, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT ALERT/EASILY AROUSABLE, INCONSISTENTLY FOLLOWS COMMANDS, MAES. PERRL, 3MM, BRISK, E-MYCIN APPLIED. FENTANYL/VERSED DRIP CONT FOR PAIN W/GOOD EFFECT.\n\nCVS: HR 80S-110S, A-FIB, SBP 110S-150S, CVP 8-16. HCT 38.2, K 4.2, QTC 0.24-0.29, HALDOL GIVEN AS ORDERED. PALP PP, FLUID BAL ~300CC/24HR.\n\nRESP: CMV VENT, 500X10/40%/10, O2 SATS>95%, NARD. LUNGS COARSE THROUGHOUT, SUCTIONED FOR SM-MOD AMTS THICK, BLOODY SECRETIONS. ABG 7.39/53/109/33, OVERBREATHING VENT BY 1-8 BPM.\n\nGI/GU: PEG PLACED TO GRAVITY, DRNG SM AMTS GREEN LIQUID. PO MEDS/TF HELD R/T PEG NOT TO BE USED PER HO. ABD SOFT, +BS, SM AMT LIQUID STOOL VIA MUSH CATH. FOLEY PATENT, HUO 60-185CC, SOME SEDIMENT NOTED, BUN 24.\n\nID: Tm 103.1, 650MG PR GIVEN, WBC 12.7 THIS AM. CONT VANCO/MEROPENEM.\n\nINTEG: SKIN W/D/I, AREA AROUND TRACH SITE CONT W/SOME OLD BLOODY DRNG.\n\nPLAN: CONT HEMODYNAMIC MONITORING/A-FIB, FENTANYL/VERSED DRIPS FOR PAIN MGMT, ?ABLE TO USE PEG TODAY. RESP SUPPORT/TRACH CARE, F/U BLOOD CX FOR TEMP SPIKES, FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-11 00:00:00.000", "description": "Report", "row_id": 1472125, "text": "resp care\nremains with #7 ,air cuff trach in place. converted to psv, requiring fairly high level of ps for poor lung compliance. sxned for small to scant bld tinged thick secretions. bs rhonchorous bilat. mdi's given per . c/w psv as tolerates, remains on peep 10.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-25 00:00:00.000", "description": "Report", "row_id": 1472051, "text": "Respiratory Care\nPt seen for BiPAP ventilation. Pt had refused BiPAP last night, and was advised to wear it and was placed onto setup. Pt started with nasal mask but complained about comfort and mask in eyes. Mask was best fit for pt. Pt later changed to hybrid mask, pt seem to be comfortable with setup. Plan is to continue BiPAP noc with new settings of 18/10 with O2 bleed in as needed per Pulmonary consult. Pt is scheduled for a sleep study on Friday. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472052, "text": "S:\"I don't want to be a attacked.\"\n\nCV:aflutter hr 80's-90's. BP 159/89. hct 46.\n\nRESP:PCO2 101 on face tent Po2 61. pt agreed to mask for bipap after much convincing. RR 35. Pt has sleep study scheduled for this Friday. LS diminished.\n\nNeuro: Pt is very anxious, pt stating \"I'm afraid to have that mask on all night.\" Pt is alert and oriented x3. pt is suspicious of all medical staff. stating \"you people use people like they are pigs\". Pt gets defensive and starts yelling then she will get very tearful and sad because she states \"I want to live, do what ever you need to do to help me stay alive\". Pt will need psych evaluation. ativan for anxiety.\n\nGU: pt has patent foley draing blood tinged urin. - 1 liter at goal.\n\nGI: pt has been using bathroom toilet. Pt has not had a bm per report from pt. pt states \"I just have gas\". Pt will not use bedpan.BS +.\n\nPain: Pt c/o pain all over and back.\n\nA:hypercapnea/sleep apnea\n\nP:Pt needs psych evaluation. continue to give emotional support. Continue to follow abgs continue to follow CIWA scale.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472053, "text": "Resp: pt on n/c @ 4 lpm, then placed on cpap 18/10 with 5 lpm 02 bleed. ABG's (see careview) Pt then place on NIV psv 12/10 and pt tolerated for 10-15 minutes then pulled off mask. co2^ 112, then intubated for impending respiratory failure. Ett#7.5, taped @ 23 lip without incident. Suctioned for moderate amounts of thick white secretions. Settings are No RSBI performed due to hemodynamic issues. ABG's pending.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472054, "text": "addendum:abg 7.22/114/67/13/49 pt was intubated. AC 50%/500/16/5. LS coarse. sxt thick white sputum. propofol gtt started pts bp low with bolus. 70's-80's\n\nID: pt now with temp 100 ax.\n\nAccess:pt has one peripheral iv. will not last long pt will need a central ine placedl.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472055, "text": "CCU NSG NOTE: ALT IN RESP\nRESP (cont). Blood gas sent on 30% AC 500 X16 5 PEEP came 7.56/ 46/ 46/ 42. It was assumed there must have been an error as there was no change in minute volume, peak pressures, rr-pt not overbreathing and sats while lower were 91-95%. However when 2 further gases were drawn the results were almost identical. HO and attending notified and FIO2 increased to 60 and rr decreased to 12b. Repeat gas is now 7.48/67/81/51.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-26 00:00:00.000", "description": "Report", "row_id": 1472056, "text": "CCU NSG NOTE: ALT IN RESP\nRESP (cont). Blood gas sent on 30% AC 500 X16 5 PEEP came 7.56/ 46/ 46/ 42. It was assumed there must have been an error as there was no change in minute volume, peak pressures, rr-pt not overbreathing and sats while lower were 91-95%. However when 2 further gases were drawn the results were almost identical. HO and attending notified and FIO2 increased to 60 and rr decreased to 12b. Repeat gas is now 7.48/67/81/51.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-09 00:00:00.000", "description": "Report", "row_id": 1472118, "text": "Addendum 0700-1900\nRt SC TLC placement confirmed by chest X-ray. Lt SC d/c'd, tip for culture sent.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-12 00:00:00.000", "description": "Report", "row_id": 1472128, "text": "pmicu npn 7p-7a\n\n the pt continued to have a low grade fever t/o most of the noc. the cooling blanket is currently off and the pt is afebrile. she received another dose of tylenol ~2300. sedation was also weaned slightly now that the pt is trached. she is responding well to verbal reassurance and has not required additional bolusing of either fentanyl or versed.\n\nreview of systems\n\nrespiratory-> pt remains trached and vented on psv18/peep10 and o2 40%. rr 20's w/tv ~350cc. suctioned several times for moderate amts of thick, yellow secretions.\n\ncardiac-> pt did receive scheduled doses of captopril and lopressor. once asleep, she did become transiently bradycardic into the 50's with sbp 90's. currently, hr 70-80's w/sbp >110. as per discussion w/team this morning, pt will likely restart on a heparin drip later this morning.\n\nneuro-> easily arousable and generally following simple commands to squeeze her hands or wiggle her toes. as noted above, she is responding to calm reassurance in lieu of sedation boluses. both versed and fentanyl drip rates reduced overnoc. mae x4 laterally on the bed but pt appears to be rather deconditioned.\n\ngi-> abd is obese w/+bs. tube feedings restarted s/p peg placement. minimal residual at the present time, so the rate was increased @0400.\ngoal rate remains @45cc/hr with free water boluses q8hrs. small bm x1 this morning. pt received bowel meds as scheduled.\n\ngu-> uop dipping to 10-20cc/hr for several hrs this am. the team is aware and will con't to monitor. the pt is currently ~350cc tfb positive since mn.\n\nid-> currently afebrile and off the cooling blanket. recultured yesterday afternoon. receiving flagyl for ?c. diff infection although stool cxs to date are negative.\n\naccess-> right sc tlcl is patent and intact.\n\nsocial-> no contact w/family overnoc.\n\ndispo-> anticipate transfer to rehab once afebrile and medically stable.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-12 00:00:00.000", "description": "Report", "row_id": 1472129, "text": "Nursing progres notes\nREview of systems:\n\nNeuro: pt more awake but comfortable titrating sedation fentanyl now on 75mcq/hr and versed to 5mg/hr. pt cont on haldol 5mg iv tid and ativan .5-2mg q 4hrs prn for anxiety and vent adaption. ativan 1mg via peg given at 1200 w/ good affect. mae follows commands. tries to mouth words. she has been crying throughout the day and mouths that she wants to go home. emotional support given.\n\nResp: pt 2 day postop trach #7 ~ on cpap 40% rr 33-45 tv 350 ls coarse w/ diminished bases. sats 95-98% suctioning thin white secretions from ett. pcxr shows white out of left lower lobe.\n\ncv: tele afib 55-80 w/ occasional pvc. hrt sounds s1s2, sbp 110-120s/60s k+ 3.7 this am repleted w/ 20meq kcl via peg. cvp 13-19 leni's neg for dvt. coumadin for afib to be restarted tonight.\n\ngi: abd obese bs+ peg tube feeds at goal 45cc/hr w/ <5cc of residual\npt on lactalose and colace no stool this shift\n\ngu: foley draining amber urine 20-40cc at one point uop stopped at 1300 lasix 40mg ivp given. pt diuresed 840cc of clear yellow urine.\n\nskin: intact\n\nid: pt cont to spike temps tmax 101.9 po tylenol given at 0800.\nantibx flagyl for ? cdiff eventhough stool samples have been neg. bc for yesturday pending. urine neg, sputum neg. cath tip neg.\n\ncode: full\n\nsocial: pt has 2 daughters one is 12yrs old and the other is 20 yrs old. contact person is pt's mother. social worker is involved.\n\nPlan:\ncont to wean vent settings\ncont to wean sedation\ngive emotional support.\nfollow temp curves.\nlabs in am.\nchest PT to left side.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-10 00:00:00.000", "description": "Report", "row_id": 1472119, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\n40 YR OLD FEMALE WITH OBESITY, CHF, AFIB, RESP FAILURE, ADMITTED WITH SOB AND HYPOXIA. NOW VENTED, HYPERCARBIC. POSS TRACH AND PEG TODAY.\n\nPT WITH FENT 125MCG/ VERSED 8MG. AROUSED EASILY ON VOICE STIMULATION, FOLLOWS COMMANDS WHEN SEDATION OFF. REQUIRES VERSED BOLUSES DURING CARE AND REPOSITION. MAE , PEERLA.\n\nREMAINS VENTED ON AC 500/50/10/10 OF PEEP/ LUNG SOUNDS CLEAR IN UPPER AIRWAYS AND DIMINISHED AT BASES. SUCTIONED AT TIME MODERATE TO LARGE AMOUNT OF THICK TAN SECRETIONS, MAINTAINS SATO2 94-99%.\n\nHEART RYTHM AFIB/AFLUTTER, HR:70S-80S, WITH OCC ECTOPIES/BP 100S-120S/MAP:60-80S. REMAINS OM METOPROLOL AND CAPTORIL.\nREMAINS FEBRILE OF UNKNOWN ORIGIN/ TMAX:101.8, IBUPROFEN GIVEN. MULTI CX ARE PENDING. CONT ON ANTBX. WBC STABLE :9.6\nAUTODIURISING/ UOP 50-120 CC/HR, FLUID BALANCE POS 1500/ LOS NEG 4L. NO SIGN OF FLUID OVERLOAD.\nCO2:38 (41), RECEIVED DIAMOX 250MG IV/K:4.2\n\nABD SOFT, POS BS. NPO POST MN FOR PROCEDURE. MUSHROOM CATH INTACT, DRAINING BROWN LIQUID STOOL/ LACTULOSE AND DOCUSATE HELD.\n\nFOLEY PATENT DRAINING YELLOW URINE WITH SOME SED.\n\nSKIN W/MOIST. PERIOD OF DIAPHORESIS NOTED/COOL COMPRESS APPLIED. MAXXAIR MATTERSS/ CONT REPOS. SKIN CARE DONE\n\nNO FAMILY CONTACT THIS SHIFT\n\nMONITOR TEMP CURVE/ FOLLOW UP CX\nPOSS OR FOR TRACH AND PEG\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-10 00:00:00.000", "description": "Report", "row_id": 1472120, "text": "Pt remains vented on AC vent . Plan is to trach pt today. She has very thk , tenacious secretions @ times that may require NS be instilled. She is on a humidifyed vent circuit. Pt getting ALB/ATR MDI Q$_^ hrs.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-10 00:00:00.000", "description": "Report", "row_id": 1472121, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: PCN, morphine\n\nEvents: Pt to OR for successful trach/PEG, also to CT scan to evaluate sinusitus.\n\nNeuro: Pt comfortable and arousable to voice on Fentanyl 125mcg/hr and Versed 8mg/hr. Bolused for turns, nursing care. Pt inconsistently following commands, spontaneous purposeful movement to all extremities. Pupils equal and reactive. Remains in bilateral soft wrist restraints for safety.\n\nCV: HR AFIB/a flutter 60-70 with occasional PVC, NBP 90-120 systolic, CVP 12-17. Pt HR to high 40s-50s this AM, team aware. Afternoon lopressor and captopril held.\n\nResp: Pt with new trach, see carevue for details. Remains vented on AC 50%/500x10/+10 with STV ~500, MV . RR 11-18 with sats >97%. Suctioned for small amounts tan, thick secretions pre-trach, post trach suctioned for moderate amounts bloody, thin secretions. Lung sounds coarse throughout. CT results pending.\n\nGI: PEG tube in place, waiting for XRAY confirmation on placement. BS x 4, mushroom catheter patent and draining small amounts of brown, liquid stool.\n\nGU: Foley patent and draining yellow urine with sediment. UO 20-30cc/hr, team aware of low UO.\n\nSkin: Intact, right SC TLC for access.\n\nID: Tmax 102.1 PO remains on ABX for PNA. Multiple cultures pending.\n\nSocial: No contact from family this shift.\n\nPlan:\nmonitor temp curve, continue with ABX\nPEG tube placement confirmation\nsedation as needed for pt comfort\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2184-06-10 00:00:00.000", "description": "Report", "row_id": 1472122, "text": "pt trached in OR with a Bavona having been placed, then brought directly to CT for scan of sinuses. plan nis to attempt wean to trach collar.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-25 00:00:00.000", "description": "Report", "row_id": 1472049, "text": "CCU NPN 7P-7A\nResp: remains on 2L NC with sats 92-99% and rr 26-30, very awake and talking continually and rapidly. ABG sent prior to placing on Bipap: 7.30/87/71 Attempted bipap, pt had it on only few minutes before insisted on taking it off, made her sick (nauseated). When pt asleep, RR 28-30, forced expiration, no periods of apnea, sats 92-95% as long as O2 on, drops to 80-78 with O2 off, and returns to 90's when O2 replaced. LS dim throughout. No cough or sputum.\n\nCV: HR 55-80's a.fib, given lopressor 25mg at hs. BP 130-160/80-90's. resume cardiac meds today.\n\nGU: foley in place UO 60-80cc/hr.\n\nGI: up to bathroom freq at least 4-5 times with c/o gas. Did have BM as well.\n\nNeuro: A&Ox3, verbalizing family troubles, history at rehab, depression, her struggles. Talking continually. No tremor, no visual or tactile hallucinations, becoming excited and very vocal when speaking to family member (mother) on phone, BP rising to 150-160's/90's, given .5mg ativan po with minimal effect. Allowed pt to vent and calmed down some. Pt requesting something to help her sleep. Trazodone order obtained, however pt sleeping before med obtained.\n\nID: afebrile\n\nSkin: intact\n\nA/P: 40 yr old with progressive SOB, felt to be primarily CHF, was diuresed, holding further diuretics for now given bump in Cr. Multiple psych/soc issues. Stopped taking medications when started drinking again. Has been part of AA program, has sponser, relapsed couple weeks ago. Expressing desire to get back on track. Social service has consulted on case. Cont with social service follow up for DC plans. Cont to follow resp status, may try bipap in light of day.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-25 00:00:00.000", "description": "Report", "row_id": 1472050, "text": "CCU Progress Note:\n\nS- \"I don't like wear that mask!\"\n\nO- see flowsheet for all objective data.\n\nresp- In O2 2L via NC - lung sounds diminished throughout- ABG this am 7.26-91-76-43- placed on BIPAP- repeat ABG 7.25-- MICU team & RT called- different BIPAP machine & mask tried- ABG 7.33-84-86-46- However, Pt refuses to leave BIPAP on long term- Presently, in O2 2L via NC- Plan is to place back on BIPAP after dinner- tachypnic @ baseline- seen by sleep study team- study scheduled for Friday .\n\ncv- Tele: Aflutter no ectopy- HR 71-89- ABP 138-158/71-109 MAPs 90-128\nrefused cardiac meds @ noon- no cardiac c/o- Hct 44.9- PT 23.2- INR 2.3- K 4.8- Mg 2.3\n\nneuro- anxious and manipulative @ times- med with ativan .5mg X1- amb well with 1 assist- follows command- PERL.\n\ngi- abd obese- (+) bowel sounds- taking Po well- had BM in bathroom today- glucose range 88-126- no insulin needed per sliding scale.\n\ngu- foley draining amber colored urine qs- blood tinged colored urine @ times due to foley trauma- (-) 300cc since 12am- no lasix given today due to rise in crea yest (1.7)- today BUN 21- Crea 1.2\n\nid- afebrile- WBC 12.7\n\ncomfort- c/o back pain & generalized discomfort- oxycodone 5mg Po given with effect @ 1500.\n\nA- 40 yr old female with progressive SOB, CHF, morbid obesity and multiple psych/soc issues (part of AA program, relapsed couple weeks ago) who con't to be hypercapnic requiring BIPAP.\n\nP- monitor vs, lung sounds, I&O and labs- place on BIPAP @ HS- follow ABG's till desired effect noted- offer emotional support- med for comfort.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-24 00:00:00.000", "description": "Report", "row_id": 1472177, "text": "Nursing Progress Note 1900-0700\n\nNeuro: A&Ox3. Very agitated at beginning of shift wanting to get OOB to go to BR, reassured, reoriented, given 2 mg IV ativan with good effect. Pt sleeping the rest of noc in naps. MAE, Good bed mobility. Continues on Seroquel TID\n\nResp: Trached, on 40% trach mask with sats 95-100%. RR 20-30, even & unlabored. + productive cough for thick white sputum. Lung sounds coarse.\n\nCardiac: Tele Aflutter 60-80 with occ PVC's. BP 100-120/60-70's. No edema + 2 pt/dp\n\nGI: Tolerating TF at goal of 45 cc/hr via PEG tube, site . + BS in 4 quadrents, abdomen obese, moderate sized loose stool this shift\n\nRenal: Foley draining adequate amounts of yellow urine with sediment. UOP 25-40 cc/hr\n\nID: afebrile, WBC stable on last day of Vanco/cefepime for PNA\n\nSKin: Intact no current issues\n\nFEN: AM labs WNL, continues on FWB 100 cc Q 6\n\nSocial: No calls from family over noc, remains full code\n\nPlan:\n\n1. ? to rehab if be available today\n2. Wean o2 as tolerated monitor resp status\n3. Encourage increase in mobility PT/OT/Speech involved\n4. Routine ICU monitoring and care\n5. Emotional support to pt\n" }, { "category": "Nursing/other", "chartdate": "2184-06-24 00:00:00.000", "description": "Report", "row_id": 1472178, "text": "Respiratory Care: Pt remained on 40% trach collar all night with cuff deflated. Received MDI's. Suctioned thick white secretions. Has been using during day. Plan is for her to return to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-24 00:00:00.000", "description": "Report", "row_id": 1472179, "text": "Nursing 0700-1230:\n\nPt to voice and oriented X three. pt able to move all extremeties with no problems. Pt OOB to chair for 2 hrs. tolerated well. TLC dressing all ports patent. Pt sent via ACLS ambulance to rehabilitation with all belongings. Mother was made aware of move yesterday by nurse. Pt talked to daughter today to inform her that she was leaving this afternoon. Pg 1,2 and 3 sent.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-09 00:00:00.000", "description": "Report", "row_id": 1472116, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\n40 YR FFEMALE WITH OBESITY, HYPOVENTILATION, RESP DISTRESS, AFIB, REMAINS VENTED, WILL BE TRACH AND PEG.\n\nEVENT: PT SELF EXTUBATED\n\nPT RECEIVED AWAKE ON FENT 100MCG/VERSED 4MG. PRESENTLY, PT IS ON FENT 125MCG/VERSED 6MG. REQUIRES MULTI BOLUSES DURING CARE AND REPOS. FOLLOWS COMMANDS WHILE AWAKE, MAE, PEERLA.\n\nHEART RYTHM AFIB WITH CONTROLLED RATE, HR 60S-80S/ OCC PVCS. SBP:90S TO 120S/ MAP 50S-70S. REMAINS ON METOPROLOL AND CAPTOPRIL\nFEBRILE/ TMAX:101.7/ PAN CX, TYLENOL 650MG GIVEN/ CURRENT T:100.7. REMAINS ON AND MEROPENEM\nK:3.9, KCL 20MEQ TO BE GIVEN\n\nSELF EXTUBATED/REINTUBATED. REMAINS ON AC 500/50%// LAST ABG: 7.52/91/52. LUNG SOUNDS COARSE THROUGHOUT. SATO2 94-98%. SUCTIONED AT TIMES MODERATE AMOUNT OF THIN WHITE SPUTUM\n\nABD SOFT POS BS. NO BM. PULM BENEPROTEIN AT GOAL RATE 45CC/HR. MINIMAL RESIDUAL. H2O FLUSH Q6HR.\n\nSKIN W/D, PT HAS PERIOD OF DIAPHORESIS. BREAKDOWN UNDER SKIN FOLDS/ SKIN CARE DONE.\n\nNO FAMILY CONTACT THIS SHIFT\n\nPT TO BE NPO ON POST MN FOR PROCEDURE/\nPOSS TRACH AND PEG\nMONITOR RESP STATUS/ KEEP PT \n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-09 00:00:00.000", "description": "Report", "row_id": 1472117, "text": "Nursing progress notes 0700-1900\nEvents: Rt SC TLC insertion.\n\nNeuro: Opens eyes to voice, MAE while awake, on Fentanyl 125 mcg/hr and Versed 6 mg/hr. Occasional attempts to get OOB, needs few boluses of sedation with activities. Bilateral wrist Soft restaints on for the Pt's safety.\n\nResp: Received on vent settings, assist control 500/50%/10/+10, sat 94-99%, LS coarse throughout. Sxn moderate amount white thick secretions via ETT. Vent settings not changed.\n\nCV: HR 68-86/min, continuous afib/a flutter with occasional PVC's. SBP 97-111, mean BP 60-84, CVP 11-17, lt SC TLC patent, site WNL. T max 101, cont on Vanco/ Meropenem. Pan culture sent last night with spike of fever. stool for c diff sent today. Electrolytes repleted in the morning. Rt SC TLC placed.\n\nGI/GU: Abdomen obese, +BS, mushroom catheter in ,draining liquid stool. TF 45 ml/hr Pulmonary Nutren with Beneprotein, minimal residual, placement checked. Foley draining yellow clear urine 25-45 ml/hr. Acetazolamide x 1 dose given. Fluid bolus 150 ml Q 8 hrs.\n\nSkin: Grossly intact, on bari-air bed.\n\nSocial: Family called , updated with .\n\nPlan: For possible TRACH/PEG tomarrow, to keep NPO post midnight.\n Aggressive pulm toileting.\n Sedation to keep comfortable.\n Follow up with culture data.\n Emotional support to the Pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-23 00:00:00.000", "description": "Report", "row_id": 1472172, "text": "PT. IS A FULL CODE.\n\nPT. IS ALLERGIC TO PCN AND MORPHINE.\n\nPT. REMAINS AWAKE AND NODS APPROPRIATELY TO QUESTIONS. PT. HAS BEEN RESTLESS AT TIMES. PT. HAS BEEN STARTED ON SERAQUEL. PT. REMAINS IN RESTRAINTS AT THIS TIME. RESTRAINTS TO LOWER EXTREMITIES WERE REMOVED AT THE BEGINNING OF THE SHIFT, AND PT TOLERATED THIS WELL. PT. HAS REMAINED AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. HAS BEEN AFLUTTER IN A CONTROLLED RATE RANGING 80-90'S, NO NOTED ECTOPY. B/P HAS BEEN STABLE AS WELL RANGING 120-130'S/80-100. PT. TOLERATED HER CAPTOPRIL, AND LOPRESSOR DOSES. BILAT PEDAL PULSES ARE WEAK BUT PALPABLE. NO PITTING EDEMA NOTED TO LOWER EXT'S.\n\nPT. HAS REMAINED ON 40% TRACH COLLAR FOR THE ENTIRE SHIFT. PT. RESP RATE REMAINED CONTROLLED AND O2 SATS RANGED 98-100% PT. HAS BEEN SUCTIONED FOR SMALL TO MODERATE AMT'S OF WHITE THIN SECRETIONS. LUNGS ARE COARSE MID TO UPPER LOBES AND DIMINISHED IN THE BASES.\n\nPT. CONTINUES ON HER TUBE FEED VIA PEGTUBE AT GOAL RATE OF 45CC/HR OF NUTREN PULMONARY WITH BENEPROTEIN. BOWEL SOUNDS ARE EASILY AUDIBLE AND PT. HAS HAD TWO MODERATE LIQUID GOLDEN STOOLS THIS SHIFT. PT. IS TO RECEIVE LACTULOSE FOR THREE STOOLS/DAY.\n\nPT. SKIN REMAINS BENIGN. PEGTUBE INSERTION SITE IS DRESSED WITH CLEAN/DRY DRESSING. TLC IS DRESSED WITH CLEAN STERILE DRESSING. ALL FOLDS ON PT. ARE SLIGHTLY REDDENED. BUT NO BREAK IN INTEGRITY. ALL THESE AREAS WERE CLEANSED, DRIED, AND POWDERED SEVERAL TIMES.\n\nPLAN: PT. WAS EVALUATED YESTERDAY FOR REHAB PLACEMENT. PT. WILL MOST LIKELY GO TOMORROW. CONTINUE TO MONITOR PULMONARY STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-23 00:00:00.000", "description": "Report", "row_id": 1472173, "text": "Resp: Pt on 40% t/c with humidification. #7 trach, secured @ 12 flange. BS are coarse with spc. Suctioned for moderate amounts of white secretions. MDI\"s administered Alb/Atr via ambu. 02 sats @ 98% Cuff deflated with no resp distres noc and tolerating well. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-23 00:00:00.000", "description": "Report", "row_id": 1472174, "text": "Resp. Care Note\nPt followed today for Albuterol and Atrovent MDI's as ordered. MDI's given in-line with ambu and spacer to trache. #7 trache with cuff deflated, 40% aerosol mask in place. Sxn and expectorating thin white secretions. Speech consult today for , pt cont to wear, speaking clearly. Plan is for transfer to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2184-06-23 00:00:00.000", "description": "Report", "row_id": 1472175, "text": "Nursing 0700-1900:\n\nNeuro: Pt to voice and oriented to person, place and time. Pt able to move all extremeties. +push = +pull, equal hand grasp, Pt is on no sedation. At times pt becomes very anxious and agitated. Pt received during shift a total of 2mg of IV ativan and a 5mg IV dose of haldol at 1731.\n\nCV: afebrile, pt continues in A-Flutter with rare PVC's, NBP 130-150/70-80's and a mean 90<. Pt has had no c/o chest pain or chest discomfort. No edema noted good CSM, +PP. capillart refill 3> sec. Pt continues to receive coumadin at HS afib/aflutter. potassium repleated with 20 Meq of KCL.\n\nGI: Abdomen soft non-tender, BS present, + flatus however no BM. TF at goal 45cc/hr with 20-25cc of residual undigested food. Pt wanting to eat and drink. Pt was continously reminded that she can not have anything by mouth. Pt was shown the TF and told that, that was the way she was getting her nutrition. Pt mouth was moitened and clean several time this shift with swabs. Pt wanting to get oob to use toilet. Pt was explained that she may use a bed pan. However, she can not get out of bed to use the toilet her mobility has declined since admition.\n\nGU: Foley draing yellow urine with sedement 30-80cc/hr. UA and culture sent at 1700. Pt continuously wanting to get out of bed to use the restroom and urinate. Pt was told and shown foley catheter and explained the purpose and reason of having it.\n\nRespiratory: Pt had placed is am. Pt is able to speak with no signs or symptoms of distress. pt has trach mask in place at 0.40% with an O2 SAT OF 100%.\n\nOther: Skin is , pt has Left TLC. Continue IV antibiotics. Blood culture was taken from line increase white count. In am. leg restrains were taken off pt more and awake. Pt was told not to attempt to get out of bed for her safety. Pt was found with legs over side rails and sliding OOB. Pt was placed back into bed and restaints were placed back. Pt sat on side of bed with nurse and PT. Pt was able to sit on the side of the bed for roughly 10minutes before she to slide off. Pt was placed back to bed and restraints placed back on. At 1300 pt had her right hand restaint removed so that she can use the phone to talk to her daughter and Mother. At 1400 pt had her LLE restaint removed along with her right arm restraint off. Pt was told that if she did not attempt to get out of bed that perhaps her LUE restraint can be removed. at 1600 pt has only her RLE with a restraint. Pt called police to file a report of abuse. The nurse talked to the police and explained the situation. The nurses name was given for documentation to the police. HO was made aware.\n\n Mother was spoken to by the nurse and informed her that the pt will not be going to rehab today special bed requierd. Pt with be sent to rehab tomorrow after noon. Mother stated that she will attempt to see pt tonight.\n\nPlan: monitor pt for safty, D/C tomorrow to rehab, conitue to provide emotional support to pt and fami\n" }, { "category": "Nursing/other", "chartdate": "2184-06-23 00:00:00.000", "description": "Report", "row_id": 1472176, "text": "(Continued)\nly.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-27 00:00:00.000", "description": "Report", "row_id": 1472059, "text": "CCU NPN 7p-12mn\nResp; vented, AC 60% 500x16 5 peep. Suctioning for thin white sputum, copious oral secretions, thick mucus from nares. LS dim throughout. sats 98%.\n\nCv: HR 90-120 afib, BP 110-140/, quickly elevated to 200/100 when suctioned, or agitated. K+ 4.7\n\nHeme: INR 3, coumadin on hold, given total 3mg vit k IV, 2 units prior to central line placement.\n\nNeuro; Pt was a&Ox3 prior to intubation, has been sedated on propofol, changed over to fent and versed this eve, up to 150mcg of fent/hr and 3mg Versed/hr. Opens eyes, reaches for ETT when awake. soft restraints in place. Very anxious when extubated and communicative.\n\nGI: NGT in place to start TF tonight. No stool today. (+)BS.\n\nGU: foley in place. UO improves when BP running higher. ~750cc.\n\nSkin: intact, multiple scarring over body from burns as 5 yr old.\n\nSoc: 20 yr old and 12 yr old daughters that live with pts mother.\npt has multiple social problems, has been in AA, now drinking. Social service has seen pt and following.\n\na/P: 40 yr old female with multiple medical and social problems, now vented for hypercarbia, has been diuresing. Not felt to have pna.\n\n" }, { "category": "Nursing/other", "chartdate": "2184-06-11 00:00:00.000", "description": "Report", "row_id": 1472126, "text": "MICU Nursing Progress Note 0700-1900\n\nCode: Full\nAllergies: PCN, morphine\n\nEvents: Pt attempting CPAP+PS, tolerating well so far, continues to be febrile, PEG tube okay'd to use, bilateral LENIS done.\n\nNeuro: Pt appears comfortable on fentanyl 125mcg/hr and versed 8mg/hr. Arousable to stimuli, bolused for turns and nursing care, spontaneous purposeful movement noted to extremities, inconsistently following commands/answering questions.\n\nCV: HR AFIB/flutter 76-97 with no ectopy noted, NBP 100-120/47-80, CVP 7-12. Peripheral pulses palpable. Bilateral LENIS done to assess for DVT, results pending. Per team will restart heparin drip for AFIB after 2nd post-op day. CVL to right SC WNL, all ports patent.\n\nResp: Pt being trialed on CPAP+PS, current settings 40%/PS18/+10 with STV ~300, MV . RR 20-30 with sats 100%. Lung sounds coarse in all fields. Suctioned x 3 for small to moderate amounts of thick, blood tinged secretions. Passy muir valve fitting/evaluation deffered until >48 hours post-op and more alert/cooperative.\n\nGI: BS x 4, rectal tube removed due to lack of stool. PEG patent and clamped, placement checked, used for meds only at this point. Nutrition consulted, recommendations in chart, will notify team. C.DIFF stool sample needed.\n\nGU: Foley patent and draining adequate amounts of yellow-amber urine with sediment.\n\nID: Tmax 102.0 PO, cooling blanket remains on. Will reculture and give PRN tylenol if temp continues to increase. ABX changed, flagyl started for possible fungal infection.\n\nSkin: Warm and dry, at times slightly diaphoretic. Trach dressing changed, site cleaned. Dressing to PEG remains intact.\n\nSocial: Mother and daughter called, updated on pt's condition and plan of care.\n\nPlan:\nwean vent as tolerated by pt\nmonitor temp curve\nABX as ordered\nfollow up culture data\nLENIS results\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2184-06-12 00:00:00.000", "description": "Report", "row_id": 1472127, "text": "Resp CAre\nPt remains on vent. No changes made. Suctioned for small amt of thick white secretions. Mdis given. Sating the in the high 90s. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-27 00:00:00.000", "description": "Report", "row_id": 1472060, "text": "MICU Nursing Progress Note 0000-0700\n\nCode: Full\nAllergies: PRN, morphine\n\nPt is 40 year old female who was transferred from CCU. Presented to ED on with dyspnea, CP and SOB (progressive dyspnea for last 2 months). Of note pt sober for several years with recent relaspe. CTA - for PE, + for PNA. Initially admitted to CCU as MICU border when she was found on 3 in early AM to be dropping sat, increasingly lethargic, tachycardic and diaphoretic. Plan in unit was for BIPAP which pt was unable to tolerate, intubated yesterday () for impeding respiratory failure - ABG 7.22/114/67/13. Tranferred to MICU for closer monitoring.\nPMH: Afib (on coumadin), CHF (EF 40%), morbidly obese, ETOH abuse, IVDA, sleep apnea (no formal sleep study done), mild pulmonary HTN, influenza .\n\nNeuro: Pt arousable to voice on 3mg/hr Versed and 150mcg/hr Fentanyl. Bolused for turns and nursing care. Following commands inconsistently, purposeful movement noted to upper extremities, able to move lower extremities. PERRL. Pt appears comfortable on aforementioned settings. Bilateral soft wrist restraints for pt safety.\n\nCV: HR AFIB 85-126 with occasional PVC, ABP 92-119/54-72, BP noted to increase with stimulation. All cardiac meds held yesterday due to low BP. Started on heparin drip for AFIB, will need PTT drawn at 0900. Crit 38.7 (46.1). Team notified. Received 2 units prior to line placement .\nResp: Pt intubated, current settings AC 500x12/+5/50%, STV ~400-500, MV . Lung sounds clear in upper lobes, diminished in lower lobes. Suctioned for moderate amounts of thick, yellow secretions in addition to moderate oral secretions. Most recent ABG 7.42/70/98/16. Will resend additional ABG as vent settings recently changed.\n\nGI: BS x 4, no stool this shift. TF started, Nutren Pulmonary running at 25cc/hr with minimal residuals with goal rate of 45cc/hr. NG tube patent, placement checked.\n\nGU: Foley patent and draining amber urine with sediment. UO increases when BP increases. AM lytes pending, will replete as ordered.\n\nSkin: Intact, multiple scars over body from burns as 5 year old.\n\nSocial: Pt is single mother, has 2 children, 20 year old and 12 year old, both living with pt's mother. In to visit yesterday, involved in mother's care. Social work following.\n\nPlan:\nmonitor HR, resp status\nmonitor ABG\nadjust heparin according to PTT results\npulmonary toileting\nroutine ICU care and monitoring\nsupport to pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-27 00:00:00.000", "description": "Report", "row_id": 1472061, "text": "Resp Care\nPt received from CCU. Pt remains intubated on full vent support. FIO2 wean to 50% this shift. Pt airtrapping +4 PEEP, therefore I-time shortened to .80. ABG on curent settings pending at this time. Pt's baseline PaCO2 approx 70 per team. MDI's given as ordered.BS clear and diminshed bilaterally, sxn for small amounts of thick yellow secretions and moderate amounts of white foamy oral secretions. Morning RSBI=152, pt became agitated during RSBI assessment. See CareVue for details and specifics.\nPlan: Maintain vent support, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-27 00:00:00.000", "description": "Report", "row_id": 1472062, "text": "NURSING NOTE 0700HRS - 1600HRS\n\n\nEVENTS..INCREASED SEDATION FOR AGITATION, LASIX FOR CHF, AIM NEG 1L..K REPLACEMENT..HCT STABLE..CVP AIM <12...AB'S COCMMENCED FOR GRAM NEG IN BC'S .RE-PAN CULTERED...\n\n\nNEURO..RECEIVED ON FENT/VERSED DRIPS 175/4, INCREASED/DECREASED WITH B/P CONTROL..RECEIVED BOLUS FOR AGITATION WHEN RE-POSTIONING/SUCTIONING..PRESENTLY SETTLED ON 175/4..PUPILS EQUAL/REACTIVE MOVEMENT OF ALL 4 LIMBS INTERMITTENTLY FOLLOWS COMMANDS..PATIENT HAS RECENT HSITORY OF ALCOHOL ABUSE/ANXIETY\n\n\nRESP..REMAINED ON AC TODAY , 12/500 PEEP @ 5 FIO2 @ 50% WITH SATISFACTORY ABG..STISFACTORY FOR PCO2 TO BE 70-80...SUCTIONED FOR THICK/WHITE YELLOW, COPIOUS ORAL THICK/YELLOW SECRETIONS ? SINUSITIS...XR SHOWS CHF, DIURSED TODAY..LUNGS SOUND COUESE/DIMINSHED\n\n\nCVS..B/P 100-120 SYSTOLIC MAPS >65 , KNOWN AF WITH LOW EF, RATE TODAY 85-95BPM..CARIAC MEDS REVIWED AND IN VIEW OF LOWER B/P AT TIMES [ DUE TO SEDTION] SOME CARDIAC MEDS STOPPED SO TO OBSERVE B/P/HR CLOSELY..K REPLACE THIS AM AND AGAIN THIS PM...\nHCT DROPPEED THIS AM TO 38, RE-CHECKED PM STABLE @ 39..? HCT DROP DUE TO RECENT LINE PLACEMENTAS HAEMATOMA EVIDENT AROUND THE SIGHT...HEPARIN STOPPED AT THIS TIME...\nB/S STABLE..\nCVP TRANSDUCED 15-20, AIM < 12\n\n\nID...AFEBRILE, BUT PREVIUOS CULTURE GREW GRAM NEG RODS THEREFORE RE-CULTERED..AB'S COMMENCED...\n\n\nGI..BELLY SOFT /OBSESE. HYPOACTIVE B/S..NO BOWEL MOTION...FEED ADVANCED TO 35..THIS PM RESIDUALS @ 60 THEREFORE NOT ADVANCED FURTHER AT THIS TIME, TO RE-CHECK AGAIN LATER...PATIENT IS CURRENTLY MENSTRAUTING\n\n\nGU...AIM FOR 1L NEG BALANCE RECEIVED 40MGS LASIX AM AND AGAIN PM..? WILL REQUIRE FURTHER DOSE TONIGHT AS ONLY JUST NEG BALAANCE AT THIS TIME..\n\n\nSKIN..ITACT, RE-POSTIONED FREQUENTLY...RT EYE DISCAHRGE EVIDENT, EYE CARE GIVEN AND ERTHROYCIN OINTMENT COMMENCED\n\n\nLINES...X2 PERIPHERAL, ART LINE...LEFTY SUBCLAVIAN LINE PLACED YESTERDAY ? HAEMATOMA AROUND THE SIGHT DUE TO THE DIFFICULTY OF INSERTION..AREA SOFT NO BLEEDING NOTED, CONTINUE TO OBSERVE..\n\n\nSOCIAL..MOTHER X2 DAUGHTERS CALLED THIS AM EXPECTED TO VISIT PM...\n\n\n\nPLAN..RESP SUPPORT , DIURSEIS..FOLLOW B/P HR CONTROL..AIM NEG BALANCE..MONITOR TEMP CURVE , CONTINUE AB'S\n" }, { "category": "Nursing/other", "chartdate": "2184-05-27 00:00:00.000", "description": "Report", "row_id": 1472063, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Continues on A/C ventilation w/ PIP/Pplat = 38/29. Briefly trialed on PSV, but sedation had just been given d/t increased agitation so Vt <150cc. BLBS coarse, diminished at bases, suctioned ETT for small amounts of thick tan secretions, copious clear oral secretions. SpO2 90s. Tolerating PaCO2 70-80. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 1472064, "text": "Resp Care\nPt remains sedated on full vent support. no vent changes made this shift. BS coarse and diminished bilaterally, suctioning for small amounts of thick yellow secretions. MDis given as ordered. Pt becoming very agitated at times needing ^ sedation. RSBI attempted but no spontaneous respirations noted and sedation unable to wean at this time. ETT retaped this morning and remains 23 @ lip. See CareVue for details and specifics.\nPlan: Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 1472065, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: PCN, morphine\n\nEvents: Sedation increased due to pt agitation, received Lasix with minimal response, temp spike to 100.7, 1 set blood cultures sent.\n\nNeuro: Pt's sedation increased to Fentanyl 250mcg/hr and Versed 7mg/hr at beginning of shift due to increasing agitation and frequent need for bolusing. Pt arousable to voice, inconsistently following commands, MAE in bed. PERRLA. Pt appears much more comfortable on increased sedation settings.\n\nCV: HR AFIB 70-95 with no ectopy noted, dilt doses held due to low BP/HR (Dr. aware), ABP 98-109/55-67, CVP ~14. AM crit stable.\n\nResp: Pt continues to be on vent support, current settings AC 500*12/+5/50%, STV ~500, MV . RR 12-20 over breathing vent while agitated, sats >95%. Suctioned for scant to small amounts of thick, white secretions. Lung sounds clear to coarse in apices, diminished in bases. AM ABG pending.\n\nGI: BS x 4, no stool this shift. TF running at goal of 45cc/hr with residuals of 20-40. Pt menstruating.\n\nGU: Foley patent and draining amber/yellow urine with sediment. Pt agitated at beginning of shift with some trauma resulting in blood tinged urine. AM K repleted. Received 40mg Lasix IVP with minimal effect, MDs aware.\n\nID: Pt spiked temp to 100.7, first set of blood cultures sent, continues on ABX therapy of Cipro.\n\nSkin: Intact, scars over torso and legs from burns as child.\n\nAccess: PIV x 4, left radial a-line, left subclavian TLC.\n\nSocial: sister and daughter in to visit last night, updated on pt's condition and plan of care.\n\nPlan:\nsedation as needed\nfollow up cultures\nsecond set of blood cultures needed\nadditional lasix for neg balance\nmonitor HR/BP\nABX as ordered\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 1472066, "text": "\\\n\n\nNURSING NOTE 0700HRS - 1600HRS\n\nADMIT TO MICU FOR WORSENING CHF, NOT TOLLERTAING BIPAP REQUIRING INTUBATION...ALCOHOL AND PREVIUOS SUBSTANCE ABUSE? ACTIVELY WITHDRAWING REQUIRING LARGE AMOUNTS OF SEDATION FOR PATEINT SAFETY...\n\n\n\nEVENTS,,SPIKED TEMP TO 101.4..LOW B/P REQURING REVIEW OF SEDATION MEDS..LASIX DRIP COMMENCED FOR LOW U/O, AIM FOR NEG BALANCE...\n\n\n\nNEURO..RECEIVED ON FENT @ 250/VERSED @ 7..PATIENTS B/P LOW TO 80\"S THEREFORE DRIPS DECREASED TO 200/5..AND HALDOL COMMENCED...B/P CONTINUED LOW AT TIMES THEREFOER DRIPS REDUCED TO 150/4 BUT PATIENT BECOMING INCRESAINGLY AGIATATED SO FURTHER STAT DOSE OF HALDOL GIVEN AND DRIPS RE-INCRESAED TO 175/5, FURTHER DOES OF HALDOL GIVEN AS THIS APPEARED TO HELP WITH LEVEL OF AGITATION..AT TIMES PATIENTS LEVEL OF AGITATION IS A DANGER TO HERSELF...SOFT RESTRAINTS REMAIN IN PLACE...PLAN IS TO CONTINIUE DRIPS FENT/VERSED , IS ON STANDING DOSE OF HALDOL ANDB TO AND LIASE WITH TEAM RE : BOLUS OF HALDOL...BOLUS OF FENT/VERSED IF REQUIRED/IF B/P TOLLERTAING...CONTINUE TO MONITOR NEURO STATUS CLOSELY...MOVEMENT OF ALL 4 LIMBS NOTED PUPILS SMALL @ 2 BUT EQULA/REACTIVE\n\n\n\nRESP...REMIANS ON AC, 500X12 50% PEEP @ 5, WITH SATISFACTORY ABG THIS AM...SUCTIONED FOR THICK WHITE SECRETIONS, LUNGS SOUND DIMINSHED CXR CONSISTENT WITH CHF..SPUTUM SPEC SENT PM..SATS REMIANED @ 98-100% MV @ ...LOW DOSE LASIX DRIP COMMENCED FOR CHF , BUT CAUTION WITH LOW B/P..\n\n\n\n\nCVS...B/P LOW @ TIMES TO 85 SYSTOLIC MAPS @ 60...AIM MAPS > 60, B/P DOES IMPROVE WITH STIMULATION OF PATIENT TO 120 SYSTOLIC, DRIPS AS ABOVE...CARDIAC MEDS HELD FOR LOW B/P...\nSPIKED TEMP PM , PAN CULTERED AND RECEIVED TYLENOL, TO OBSERVE FOR SEPTIC PICTURE..AB'S CONTINUE...\nLASIX STARTED AT VERY LOW DOSE OF 5MGS /HR..AIM IS FOR 1-2L NEG BUT IN VIEW OF B/P ISSUES WILL NOT ACHIEVE TODAY, TEAM AWARE...\nPM LABS PENDING...B/S STABLE...CVP 15-17...QTC FOR HALDOL @ 0.43 TODAY\n\n\nGI..FEED AT GOAL @ 45, BOWEL REGIME COMMENCED AS NO MOTION SINCE ADMISSION...NO RESIDUALS, HYPOACTIVE B/S...\n\n\nGU...U/O 15-35 TODAY [ TEAM AWARE THAT PATIENT IS POS TODAY]...TITRATE LASIX DRIP AS B/P TOLLERATES, MAINTAINING MAPS >60\n\n\nSKIN..INTACT, CONTINUES TO MENSTRUATE\n\nLINES..X2 PERIPHEWRAL REMOVED...\n\n\nSOCIAL..DAUGHETR HAS CALLED TODAY ? TO VISIT THIS EVE..\n\n\nPLAN..ADEQUATE SEDATION, MAINTAING MAPS >60..LASIX FOR UO, MAINATING MAPS > 60...FOLLOW TEMP CURVE...\n" }, { "category": "Nursing/other", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 1472067, "text": "Resp Care\nPt remains inutbated on full support. Current vent settings: A/C 500 x 12 5P 50%. Attempted PS, but Pt did not tolerate. No RSBI due to agitation. MDI's given, no other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2184-05-28 00:00:00.000", "description": "Report", "row_id": 1472068, "text": "NURSING ATTENDUM...LIASED WITH ATTENDING RE: AGITATION ISSUES..PATIENT HAS RECEIVED INCREASED DOSES OF FENT/VERSED WITH HALDOL THIS AFTERNOON WITH LITTLE AFFECT ... PLAN IS TO INCREASE VERSED FOR POSSIBLE ALCOHOL WITHDRAWL, BACK OF WITH VENT AND INTRODUCE NEO IF NEEDED TO MAINTAIN MAPS >60\n" }, { "category": "Nursing/other", "chartdate": "2184-05-29 00:00:00.000", "description": "Report", "row_id": 1472069, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: PCN, morphine\n\nPt admitted to MICU for worsening CHF, unable to tolerate BIPAP therefore intubated for impending respiratory failure. Pt with known history of ETOH and IVDA, was on CIWA scale prior to intubation, actively withdrawing and requiring large amounts of sedation for pt safety.\n\nNeuro: Pt arousable to voice on Fentanyl 150mcg/hr and Versed 7mg/hr, also receiving haldol TID for agitation with good effect. QTc being monitored, most recent 0.45 before 4AM dose. BP tolerating sedation well. Pt appearing much more comfortable with little agitation noted. Pt not following commands, able to move all extremities, pupils small but remain equal and reactive.\n\nCV: HR AFIB 76-83 with rare PVC, ABP 100-111/55-60, MAPs in 70's with goal >60, CVP 13-15 with goal <12. Neo on hand should pt become danger to herself or staff and require increased amounts sedation and BP cannot tolerate, however pt not requiring at this time. Crit stable. For access pt has left subclavian TLC and right radial a-line. Lasix started for volume overload/CHF. Per team request will diurese as BP tolerates, however neo may be started if pt drops pressure but continues to have good urine output.\n\nResp: Pt remains on vent support, current settings 500*12/+5/50%, STV ~500, MV . Suctioned for small to moderate amounts of thick, clear to white secretions. Lung sounds clear in apices, diminished in bases. Sputum cultures from pending. AM ABG pending.\n\nGI: BS x 4, no stool since admission. TF held x 1 hour for TF like secretions from mouth (no drop in sat noted), NG tube set to wall suction and 100cc residual removed. Restarted at 25cc/hr with moderate residuals - team aware. Pt lightly menstruating.\n\nGU: Foley patent and draining large amounts of clear, light yellow urine. UO 45-340cc/hr. Pt negative 500cc since midnight, goal is negative 1-2L for today.\n\nID: Tmax 100.6 PO. Pt pan cultured for temp spike, all results pending. Pt continues on ABX therapy (Vanco/Meropenum/Cipro). Pt with known sensitivity to PCN, Meropenum okayed by MICU team and ID, no reaction noted.\n\nSkin: Intact, scars to torso and legs from burns as child.\n\nSocial: No contact from family overnight.\n\nPlan:\ndiurese as BP tolerates (MAPs >60), neo if necessary\nmonitor UO/fluid balance\nsedation as needed for pt safety\nmonitor QTc\nfollow temp\nABX as ordered\nroutine ICU care and monitoring\nsupport to pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2184-05-29 00:00:00.000", "description": "Report", "row_id": 1472070, "text": "Resp Care\nPt remains intubated on full vent support. No vent changes made this shift. BS slightly coarse and diminished bilaterally. Suctioned for small amounts of clear/white thick secretions. RSBI attempted, however no spontaneous respirations noted. Pt continues episodes of agitation when stimulated. See CareVue for details and specifics.\nPlan: Maintain vent support, wean as tolerated.\n" } ]

[ { "category": "Physician ", "chartdate": "2117-02-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 718493, "text": "Chief Complaint:\n Chief Complaint: rectal bleeding\n Reason for MICU admission: LGIB with low Hct\n HPI:\n 81F with atrial fibrillation on coumadin, Hep B without ESLD, s/p\n colonoscopy 8 days PTA, presenting with 7 days of mild rectal bleeding\n with 2 days of heavier bleeding and finding of low hematocrit as an\n outpatient. She had routine outpatient colonoscopy at on .\n Daughter reports polyps removed, but report not yet available. She had\n stopped coumadin prior to procedure, and resumed use the day following\n her procedure. Since the procedure she has noted small amounts of red\n blood in her stools. Then two day ago she had a large bowel movement\n which was basically all red blood. Since then she has had 5 similar\n bowel movements. No abdominal pain, but notes a gassy feeling. Has\n felt fatigued with activity and daughter notes she slept in today. Has\n had decreased PO intake and little interest in food since colonoscopy,\n but most notably in past 2 days since larger bleeding started. Also\n notes a feeling of her heart pounding earlier today. No chest pain or\n dyspnea. No fever. No lightheadedness or presyncope. She presented\n to her PCP today, thought ?related to colonoscopy vs. viral\n gastroenteritis. Prescribed lomotil and took one dose today. Labs\n returned with hematocrit of 24.1. She was therefore referred to the\n ED.\n .\n In the ED, initial vs were: T98.1 P71 123/34 16 100% on RA. Vital\n signs remained stable throughout ED course. BRB on rectal exam. Hct\n 21.9 and INR 2.4. Given 5 mg IV vitamin K, ordered for FFP and typed\n and crossed for 2 units PRBCs. GI paged but have not yet called back.\n Admitted to MICU given severity of anemia, age, unclear how fast she is\n bleeding.\n .\n On the floor, patient reports feeling well, just fatigued. No\n abdominal pain.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies: lisinopril\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n - Coumadin 2.5 mg Tue/Fri, 2 mg other days\n - Avapro 150 mg daily\n - Metoprolol 25 mg daily\n - Fosamax 70 mg weekly\n - Simvastatin 20 mg daily\n - Multivitamin daily\n - vitamin D 1000 units daily\n - Fish oil 1000 mg daily\n Past medical history:\n Family history:\n Social History:\n - Atrial fibrillation, most recently in sinus. On beta blocker and\n coumadin.\n - Hepatitis B. No evidence of cirrhosis ever. Recent labs () with\n viral load of 431 and normal LFTs.\n - Hypertension\n - ?Past CVA or TIA (had weakness of fingers of one hand, which\n resolved)\n - Hyperlipidemia\n - Osteopenia/osteoporosis\n - ?Elevated fasting glucose - \"being watched\" per daughter.\n - s/p cataract surgery , no complications.\n daughter with kidney stones.\n Social History: Lives with daughter and granddaughter. works\n full time.\n - Tobacco: remote history of occasional smoking, quit > 45 years ago.\n - Alcohol: none\n - Illicits: none\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, cough, shortness of breath, or wheezing. Denies chest\n pain, chest pressure, nausea, vomiting, dysuria, frequency, or urgency.\n Denies rashes or skin changes.\n Flowsheet Data as of 01:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 68) bpm\n BP: 116/44(63) {109/35(63) - 116/44(99)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 800 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 300 mL\n 0 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 500 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General: Appears younger than stated age, alert, oriented, no distress.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVD 2-3 cm ASA, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi,\n some decrease at bases.\n CV: Regular rate and rhythm, normal S1 + S2, soft SM at RUSB and at\n apex. No significant radiation to carotids.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n Neuro: CN II-XII intact. Strength 5/5 in UEs and LEs.\n Labs / Radiology\n 139\n [image002.gif]\n 107\n [image002.gif]\n 24\n [image004.gif]\n 132\n AGap=13\n [image005.gif]\n 3.8\n [image002.gif]\n 23\n [image002.gif]\n 0.8\n [image007.gif]\n 93\n 6.7\n [image007.gif]\n 7.4\n [image004.gif]\n 216\n [image008.gif]\n [image004.gif]\n 21.9\n [image007.gif]\n N:53.0 L:40.0 M:4.7 E:1.3 Bas:1.1\n PT: 25.4\n PTT: 34.1\n INR: 2.4\n UA negative\n Lactate 1.7\n Micro: none\n .\n Images: none\n .\n EKG: NSR at 65, prolonged PR, normal axis, no ST/T wave ischemic\n changes.\n Assessment and Plan\n 81F with atrial fibrillation on coumadin, chronic HBV without ESLD,\n presenting with BRBPR s/p colonoscopy one week ago.\n .\n # BRBPR. Presenting with 2 days of rectal bleeding. Given overall\n hemodynamic stability, consistent with LGIB. Bleeding painless. In\n setting of having a colonoscopy one week ago - high suspicion for\n post-polypectomy bleed, particularly since has been having smaller\n amounts of bleeding since the procedure. Other differential includes\n diverticulosis, AVMs, ischemic colitis, hemorrhoids, bleeding from\n other polyps/cancerous lesions. Patient does carry diagnosis of Hep B\n with positive viral loads (though low VLs) - no evidence of ESLD.\n Overall hopeful for stabilization and cessation of bleeding with\n reversal of anticoagulation, though may need revisualization\n - NPO.\n - Maintain good IV access 18g x2.\n - GI aware and will see in AM, hold off on prep until stabilized but\n will likely need colonoscopy.\n - Obtain records re: colonoscopy findings and sites of polypectomy\n (may be able to get away with flex sig).\n - General surgery consult if continues to bleed.\n - If no source obvious after colonoscopy or brisker bleed, will send to\n nuclear +/- IR for potential angio.\n - Patient being reversed with IV vitamin K and FFP; consider more if\n continued bleeding with persistently elevated coags.\n - Transfuse 2 units PRBCs.\n - IV NS if clinically appears hypovolemic.\n - Consider IV PPI if suspicion for lower source.\n .\n # Atrial fibrillation. On coumadin. Currently in sinus.\n - Holding anticoagulation as above.\n - Holding rate meds in setting of acute bleed.\n .\n # Hypertension. Normotensive here.\n - Hold BP meds in setting of bleeding.\n .\n # Osteoporosis vs. penia.\n - Holding fosamax.\n .\n # FEN: Bolus prn, replete electrolytes, NPO.\n # Prophylaxis: Boots for now, start HSQ tomorrow with monitoring of PTT\n if bleeding improves.\n # Access: peripherals 18g x 2 (or less ideally 20, 18).\n # Communication: Patient and daughter\n # Code: Full\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:45 PM\n 20 Gauge - 11:46 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2117-02-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 718579, "text": "Pt is a 81 yo Chinese woman who had a colonoscopy on which revealed\n 3 cecal polyps. She then restarted her coumadin ( on this for hx afib)\n over next couple of days had several episodes of BRBPR and was very\n tired. Went to PCD where hct was 25, then to EW where hct was 21.8. INR\n was 2.4- tx with Vit K. Tx to the MICU for further care.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft and distended, has small amt + flatus and\ngassy pains\n. Has\n had no stool all day. Was NPO until 5 pm when she took her po meds with\n water.\n Action:\n Tx with a total of 4 units prbcs and 2 units ffp in micu,\n Response:\n Hct had increased to 25.8 halfway through 3^rd unit- pm hct=\n INR has improved to 1.4.\n Plan:\n Will follow for any stool output. Advance diet as per Gi team. Follow\n serial hcts\n Brief review of systems:\n CV- vs have been stable. No c/o chest pain or palps. Has hx of afib,\n has been in nsr here. RESP- wearing 2L nasal cannula most of the day\n with o2 sats > 96%. Lungs clear with slight diminished at bases. NEURO-\n speaks Cantonese. Is alert and oriented x 3 as per daughter. Very\n cooperative. Good gag and cough reflex. F/E- receiving kvo\n maintainence fluid. Is voiding adequate amts clear yellow urine via\n foley. No edema noted. ID- afeb- temp 99.1 max po. No issues. IV\n access- has a 318 L, # 20 R. Social- daughter in all day,\n granddaughter in also afternoon.\n" }, { "category": "Physician ", "chartdate": "2117-02-07 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 718544, "text": "Chief Complaint: GI Bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 81 yo F with afib, on coumadin\n S/P colonoscopy 8d prior to admission. Presented with 7d of rectal\n bleeding. Had colonoscopy . Pt thinks she had polypectomy but we\n do not have records of procedure. Restarted coumadin day following\n . Had mild rectal bleeding until had BRBPR larger amount,\n continued to have bloody stools with BRB 2-3 per day until presented to\n her PCP. c/o palpitations. PCP checked hct 24.1%. Denied chest pain,\n dyspnea, n/v.\n In ED 123/34 HR 71 100% on RA. BRB on rectal exam in ED but no BM. INR\n 2.4.\n Sinus rhythm.\n Hemodynamically stable since arrival. Beta blocked.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hep B\n HTN\n question of prior CVA or TIA\n hyperlipidemia\n osteopenia/porosis\n Home meds:\n coumadin\n metoprolol\n avapro\n MVI\n statin\n fosomax\n vit D\n Allergies: lisinopril causes cough\n NC\n Occupation:\n Drugs: none\n Tobacco: remote\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, Palpitations, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n \"gassy\"\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:42 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 60 (57 - 68) bpm\n BP: 108/41(58) {94/34(50) - 116/44(99)} mmHg\n RR: 21 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 800 mL\n 1,212 mL\n PO:\n TF:\n IVF:\n Blood products:\n 1,212 mL\n Total out:\n 300 mL\n 450 mL\n Urine:\n 300 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 500 mL\n 762 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No edema\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x4, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 140 K/uL\n 23.8 %\n 8.4 g/dL\n 98 mg/dL\n 0.7 mg/dL\n 17 mg/dL\n 27 mEq/L\n 109 mEq/L\n 3.6 mEq/L\n 143 mEq/L\n 5.0 K/uL\n [image002.jpg]\n 06:43 AM\n WBC\n 5.0\n Hct\n 23.8\n Plt\n 140\n Cr\n 0.7\n Glucose\n 98\n Other labs: PT / PTT / INR:16.3/30.2/1.4, Ca++:7.8 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: 21.9--> 23.8% after 2U PRBC\n ECG: NSR. Mildly prolonged PR interval. No ischemic changes.\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 11:45 PM\n 20 Gauge - 11:46 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2117-02-07 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 718547, "text": "Chief Complaint: GI Bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 81 yo F with afib, on coumadin\n S/P colonoscopy 8d prior to admission. Presented with 7d of rectal\n bleeding. Had colonoscopy . Pt thinks she had polypectomy but we\n do not have records of procedure. Restarted coumadin day following\n . Had mild rectal bleeding until had BRBPR larger amount,\n continued to have bloody stools with BRB 2-3 per day until presented to\n her PCP. c/o palpitations. PCP checked hct 24.1%. Denied chest pain,\n dyspnea, n/v.\n In ED 123/34 HR 71 100% on RA. BRB on rectal exam in ED but no BM. INR\n 2.4.\n Sinus rhythm.\n Hemodynamically stable since arrival. Beta blocked.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hep B\n HTN\n question of prior CVA or TIA\n hyperlipidemia\n osteopenia/porosis\n Home meds:\n coumadin\n metoprolol\n avapro\n MVI\n statin\n fosomax\n vit D\n Allergies: lisinopril causes cough\n NC\n Occupation:\n Drugs: none\n Tobacco: remote\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, Palpitations, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n \"gassy\"\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:42 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 60 (57 - 68) bpm\n BP: 108/41(58) {94/34(50) - 116/44(99)} mmHg\n RR: 21 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 800 mL\n 1,212 mL\n PO:\n TF:\n IVF:\n Blood products:\n 1,212 mL\n Total out:\n 300 mL\n 450 mL\n Urine:\n 300 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 500 mL\n 762 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, no acute distress, very comfortable\n and well appearing.\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: Clear with good air movement except faint crackles\n bilat bases.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No edema\n Skin: Warm, No(t) Rash: Faint bruise over left shin.\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x4, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 140 K/uL\n 23.8 %\n 8.4 g/dL\n 98 mg/dL\n 0.7 mg/dL\n 17 mg/dL\n 27 mEq/L\n 109 mEq/L\n 3.6 mEq/L\n 143 mEq/L\n 5.0 K/uL\n [image002.jpg]\n 06:43 AM\n WBC\n 5.0\n Hct\n 23.8\n Plt\n 140\n Cr\n 0.7\n Glucose\n 98\n Other labs: PT / PTT / INR:16.3/30.2/1.4, Ca++:7.8 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: 21.9--> 23.8% after 2U PRBC\n ECG: NSR. Mildly prolonged PR interval. No ischemic changes.\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n most likely post-polypectomy.\n Just learned pt had 3 polyps removed from cecum 8d ago.\n INR reversed with Vit K IV 5mg. 2U FFP given last night in MICU.\n Repeat INR 1.4.\n Inappropriate rise in hct, giving 2U more (total 4U) PRBC.\n GI aware of pt. Plan for colonoscopy to evaluate area of polypectomy\n and other possible etiologies of BRBPR. If hct does not rise\n appropriately or if she has significant lower bleeding will involve\n surgery and IR.\n Afib, sinus rhythm now with AV nodal blockade, HR 58.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 11:45 PM\n 20 Gauge - 11:46 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now, recheck hct post-transfusion.\n Total time spent: 35 minutes.\n Critically ill.\n" }, { "category": "Physician ", "chartdate": "2117-02-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 718551, "text": "Chief Complaint:\n Chief Complaint: rectal bleeding\n Reason for MICU admission: LGIB with low Hct\n HPI:\n 81F with atrial fibrillation on coumadin, Hep B without ESLD, s/p\n colonoscopy 8 days PTA, presenting with 7 days of mild rectal bleeding\n with 2 days of heavier bleeding and finding of low hematocrit as an\n outpatient. She had routine outpatient colonoscopy at on .\n Daughter reports polyps removed, but report not yet available. She had\n stopped coumadin prior to procedure, and resumed use the day following\n her procedure. Since the procedure she has noted small amounts of red\n blood in her stools. Then two day ago she had a large bowel movement\n which was basically all red blood. Since then she has had 5 similar\n bowel movements. No abdominal pain, but notes a gassy feeling. Has\n felt fatigued with activity and daughter notes she slept in today. Has\n had decreased PO intake and little interest in food since colonoscopy,\n but most notably in past 2 days since larger bleeding started. Also\n notes a feeling of her heart pounding earlier today. No chest pain or\n dyspnea. No fever. No lightheadedness or presyncope. She presented\n to her PCP today, thought ?related to colonoscopy vs. viral\n gastroenteritis. Prescribed lomotil and took one dose today. Labs\n returned with hematocrit of 24.1. She was therefore referred to the\n ED.\n .\n In the ED, initial vs were: T98.1 P71 123/34 16 100% on RA. Vital\n signs remained stable throughout ED course. BRB on rectal exam. Hct\n 21.9 and INR 2.4. Given 5 mg IV vitamin K, ordered for FFP and typed\n and crossed for 2 units PRBCs. GI paged but have not yet called back.\n Admitted to MICU given severity of anemia, age, unclear how fast she is\n bleeding.\n .\n On the floor, patient reports feeling well, just fatigued. No\n abdominal pain.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies: lisinopril\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n - Coumadin 2.5 mg Tue/Fri, 2 mg other days\n - Avapro 150 mg daily\n - Metoprolol 25 mg daily\n - Fosamax 70 mg weekly\n - Simvastatin 20 mg daily\n - Multivitamin daily\n - vitamin D 1000 units daily\n - Fish oil 1000 mg daily\n Past medical history:\n Family history:\n Social History:\n - Atrial fibrillation, most recently in sinus. On beta blocker and\n coumadin.\n - Hepatitis B. No evidence of cirrhosis ever. Recent labs () with\n viral load of 431 and normal LFTs.\n - Hypertension\n - ?Past CVA or TIA (had weakness of fingers of one hand, which\n resolved)\n - Hyperlipidemia\n - Osteopenia/osteoporosis\n - ?Elevated fasting glucose - \"being watched\" per daughter.\n - s/p cataract surgery , no complications.\n daughter with kidney stones.\n Social History: Lives with daughter and granddaughter. works\n full time.\n - Tobacco: remote history of occasional smoking, quit > 45 years ago.\n - Alcohol: none\n - Illicits: none\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, cough, shortness of breath, or wheezing. Denies chest\n pain, chest pressure, nausea, vomiting, dysuria, frequency, or urgency.\n Denies rashes or skin changes.\n Flowsheet Data as of 01:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 68) bpm\n BP: 116/44(63) {109/35(63) - 116/44(99)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 800 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 300 mL\n 0 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 500 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General: Appears younger than stated age, alert, oriented, no distress.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVD 2-3 cm ASA, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi,\n some decrease at bases.\n CV: Regular rate and rhythm, normal S1 + S2, soft SM at RUSB and at\n apex. No significant radiation to carotids.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n Neuro: CN II-XII intact. Strength 5/5 in UEs and LEs.\n Labs / Radiology\n 139\n [image002.gif]\n 107\n [image002.gif]\n 24\n [image004.gif]\n 132\n AGap=13\n [image005.gif]\n 3.8\n [image002.gif]\n 23\n [image002.gif]\n 0.8\n [image007.gif]\n 93\n 6.7\n [image007.gif]\n 7.4\n [image004.gif]\n 216\n [image008.gif]\n [image004.gif]\n 21.9\n [image007.gif]\n N:53.0 L:40.0 M:4.7 E:1.3 Bas:1.1\n PT: 25.4\n PTT: 34.1\n INR: 2.4\n UA negative\n Lactate 1.7\n Micro: none\n .\n Images: none\n .\n EKG: NSR at 65, prolonged PR, normal axis, no ST/T wave ischemic\n changes.\n Assessment and Plan\n 81F with atrial fibrillation on coumadin, chronic HBV without ESLD,\n presenting with BRBPR s/p colonoscopy one week ago.\n .\n # BRBPR. Presenting with 2 days of rectal bleeding. Given overall\n hemodynamic stability, consistent with LGIB. Bleeding painless. In\n setting of having a colonoscopy one week ago - high suspicion for\n post-polypectomy bleed, particularly since has been having smaller\n amounts of bleeding since the procedure. Other differential includes\n diverticulosis, AVMs, ischemic colitis, hemorrhoids, bleeding from\n other polyps/cancerous lesions. Patient does carry diagnosis of Hep B\n with positive viral loads (though low VLs) - no evidence of ESLD.\n Overall hopeful for stabilization and cessation of bleeding with\n reversal of anticoagulation, though may need revisualization\n - NPO.\n - Maintain good IV access 18g x2.\n - GI aware and will see in AM, hold off on prep until stabilized but\n will likely need colonoscopy.\n - Obtain records re: colonoscopy findings and sites of polypectomy\n (may be able to get away with flex sig).\n - General surgery consult if continues to bleed.\n - If no source obvious after colonoscopy or brisker bleed, will send to\n nuclear +/- IR for potential angio.\n - Patient being reversed with IV vitamin K and FFP; consider more if\n continued bleeding with persistently elevated coags.\n - Transfuse 2 units PRBCs.\n - IV NS if clinically appears hypovolemic.\n - Consider IV PPI if suspicion for lower source.\n .\n # Atrial fibrillation. On coumadin. Currently in sinus.\n - Holding anticoagulation as above.\n - Holding rate meds in setting of acute bleed.\n .\n # Hypertension. Normotensive here.\n - Hold BP meds in setting of bleeding.\n .\n # Osteoporosis vs. penia.\n - Holding fosamax.\n .\n # FEN: Bolus prn, replete electrolytes, NPO.\n # Prophylaxis: Boots for now, start HSQ tomorrow with monitoring of PTT\n if bleeding improves.\n # Access: peripherals 18g x 2 (or less ideally 20, 18).\n # Communication: Patient and daughter\n # Code: Full\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 11:45 PM\n 20 Gauge - 11:46 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: NA, consider PPI/H2B\n VAP:\n Comments:\n Communication: Comments: patient and daughter\n status: Full (discussed with patient and daughter)\n Disposition: ICU pending Hct stabillity and procedural decision by GI\n" }, { "category": "Nursing", "chartdate": "2117-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 718524, "text": "Pt is s/p routine colonoscopy as of , which was negative. Since\n then, she has had liquid BRBPR. Today she felt very tired and went to\n the clinic were they found her hct to be 25. Pt sent to for\n further care. Hct in EW, was 21. VSS. inr 2.4 and given 5 mg of vit K\n IV. Pt sent to MICU for further care.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft , slight distended and non-tender to palp. BS +. No N/V per\n pt. Pt has not had a BM since adm to . VSS as noted.\n Action:\n Pt given 2 units of PRBCs and 2 units of FFP and labs due to be drawn\n this am at 6am after blood transfusions MD.\n Response:\n Hct level pending. No further GIB noted and VS remains stable.\n Plan:\n Continue monitor Hct level closely and monitor for GIB. ? C/O to floor\n later this pm if pt remains stable.\n" }, { "category": "Nursing", "chartdate": "2117-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 718509, "text": "Pt is s/p routine colonoscopy as of , which was negative. Since\n then, she has had liquid BRBPR. Today she felt very tired and went to\n the clinic were they found her hct to be 25. Pt sent to for\n further care. Hct in EW, was 21. VSS. inr 2.4 and given 5 mg of vit K\n IV. Pt sent to MICU for further care.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft , slight distended and non-tender to palp. BS +. No N/V per\n pt. Pt has not had a BM since adm to . VSS as noted.\n Action:\n Pt given 2 units of PRBCs and labs due to be drawn this am at 6am after\n blood transfusions MD.\n Response:\n Hct level pending. No further GI noted and VS remains stable.\n Plan:\n Continue monitor Hct level closely and monitor for GIB. ? C/O to floor\n later this pm if pt remains stable.\n" }, { "category": "Nursing", "chartdate": "2117-02-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 718585, "text": "Pt is a 81 yo Chinese woman who had a colonoscopy on which revealed\n 3 cecal polyps. She then restarted her coumadin ( on this for hx afib)\n over next couple of days had several episodes of BRBPR and was very\n tired. Went to PCD where hct was 25, then to EW where hct was 21.8. INR\n was 2.4- tx with Vit K. Tx to the MICU for further care.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft and distended, has small amt + flatus and\ngassy pains\n. Has\n had no stool all day. Was NPO until 5 pm when she took her po meds with\n water.\n Action:\n Tx with a total of 4 units prbcs and 2 units ffp in micu,\n Response:\n Hct had increased to 25.8 halfway through 3^rd unit- pm hct=32\n INR has improved to 1.4.\n Plan:\n Will follow for any stool output. Advance diet as per Gi team. Follow\n serial hcts\n Brief review of systems:\n CV- vs have been stable. No c/o chest pain or palps. Has hx of afib,\n has been in nsr here. RESP- wearing 2L nasal cannula most of the day\n with o2 sats > 96%. Lungs clear with slight diminished at bases. NEURO-\n speaks Cantonese. Is alert and oriented x 3 as per daughter. Very\n cooperative. Good gag and cough reflex. F/E- receiving kvo\n maintainence fluid. Is voiding adequate amts clear yellow urine via\n foley. No edema noted. ID- afeb- temp 99.1 max po. No issues. IV\n access- has a 318 L, # 20 R. Social- daughter in all day,\n granddaughter in also afternoon.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n LOWER GI BLEED\n Code status:\n Height:\n Admission weight:\n 57.4 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history: HTN, A-fib on coumadin, eyesurgery on steroid gtts.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:140\n D:39\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 56 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,942 mL\n 24h total out:\n 755 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 06:43 AM\n Potassium:\n 3.6 mEq/L\n 06:43 AM\n Chloride:\n 109 mEq/L\n 06:43 AM\n CO2:\n 27 mEq/L\n 06:43 AM\n BUN:\n 17 mg/dL\n 06:43 AM\n Creatinine:\n 0.7 mg/dL\n 06:43 AM\n Glucose:\n 98 mg/dL\n 06:43 AM\n Hematocrit:\n 32.7 %\n 05:52 PM\n Finger Stick Glucose:\n 110\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: wedding ring- yelow metal\n Transferred from: micu 6\n Transferred to: cc7\n Date & time of Transfer01/17/10 1840\n" }, { "category": "ECG", "chartdate": "2117-02-16 00:00:00.000", "description": "Report", "row_id": 232109, "text": "Atrial flutter with rapid ventricular response. Compared to the previous\ntracing of atrial flutter with rapid ventricular response is now\nrecorded.\n\n" }, { "category": "ECG", "chartdate": "2117-02-16 00:00:00.000", "description": "Report", "row_id": 232110, "text": "The second and third beats of the tracing show atrial pacer activity followed\nby sinus rhythm. Precordial lead ST-T wave abnormalities are non-specific.\nClinical correlation is suggested. Since the previous tracing of \natrial flutter is now absent and ST-T wave changes have decreased.\n\n" }, { "category": "ECG", "chartdate": "2117-02-14 00:00:00.000", "description": "Report", "row_id": 232111, "text": "Irregular supraventricular tachycardia that is most likely atrial flutter with\nvariable block. Non-specific ST-T wave changes. Compared to the previous\ntracing the rhythm has changed.\n\n" }, { "category": "ECG", "chartdate": "2117-02-11 00:00:00.000", "description": "Report", "row_id": 232112, "text": "Sinus bradycardia. P-R interval prolongation. Consider left atrial\nabnormality. RSR' pattern in leads V1-V2 with T wave inversions in\nleads V1-V2. Since the previous tracing of the RSR' pattern in\nleads V1-V2 is now seen, probably related to differences in lead position.\n\n" }, { "category": "ECG", "chartdate": "2117-02-08 00:00:00.000", "description": "Report", "row_id": 232113, "text": "Sinus bradycardia with A-V conduction delay. Consider biatrial abnormality\nalthough is non-diagnostic. Modest ST-T wave changes are non-specific. Since\nthe previous tracing of same date atrial flutter is now absent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2117-02-08 00:00:00.000", "description": "Report", "row_id": 232114, "text": "Atrial flutter. Modest ST-T wave changes are non-specific. Since the previous\ntracing of same date the ventricular rate is slower and ST-T wave abnormalities\nhave decreased.\nTRACING 3\n\n" }, { "category": "ECG", "chartdate": "2117-02-08 00:00:00.000", "description": "Report", "row_id": 232115, "text": "Probable atrial flutter with rapid ventricular response. Diffuse ST-T wave\nabnormalities are non-specific but cannot exclude myocardial ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of \ntachy-arrhythmia and further ST-T wave abnormalities are now present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2117-02-06 00:00:00.000", "description": "Report", "row_id": 305081, "text": "Sinus rhythm with A-V conduction delay. Non-specific inferior ST-T wave change.\nNo previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2117-02-10 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 1117456, "text": " 7:00 PM\n FOOT AP,LAT & OBL RIGHT; ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: eval for signs of bony destruction\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with R medial foot redness, swelling, pain and tenderness,\n concern for gout vs pseudogout\n REASON FOR THIS EXAMINATION:\n eval for signs of bony destruction\n ______________________________________________________________________________\n WET READ: DLrc WED 9:18 PM\n No evidence of gross bony disruption or dystrophic calcification. Medial soft\n tissue swelling not well appreciated.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FOOT \n\n CLINICAL INFORMATION: Evaluate for signs of bony destruction, right medial\n foot redness.\n\n Five total images of the right foot and lower leg are submitted. The bones\n are osteopenic. There is a small ankle joint effusion. There are mild\n degenerative changes at the tibiotalar joint and talonavicular joint. No\n acute abnormality is noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-02-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1118174, "text": " 9:50 AM\n CHEST (PA & LAT) Clip # \n Reason: new ppm lead placement.\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with new dual chamber ppm\n REASON FOR THIS EXAMINATION:\n new ppm lead placement.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: New dual chamber pacemaker.\n\n IMPRESSION: PA and lateral chest reviewed in the absence of prior chest\n radiographs:\n\n Transvenous right atrial and right ventricular pacer leads follow their\n expected courses from the left axillary pacemaker. No pneumothorax or\n mediastinal widening is present. Lateral view shows a very small pleural\n effusion collected posteriorly. Heart size normal, probable small pericardial\n effusion projects to the left of the cardiac apex, but there is no mediastinal\n vascular engorgement to suggest that this is hemodynamically significant.\n Vascular deficiency in the right upper lobe is probably due to emphysema. No\n focal pulmonary abnormality is seen elsewhere.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2116-12-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 812043, "text": " 5:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with acute change in mental status, eyes deviated to right\n REASON FOR THIS EXAMINATION:\n eval for bleed\n CONTRAINDICATIONS for IV CONTRAST:\n allergy\n ______________________________________________________________________________\n WET READ: 8:00 PM\n FLUID COLLECTION WITH BONE DESTRUCTION RELATED TO ANTERIOR HARD PALATE AND\n LEFT MAXILLARY SINUS, INCOMPLETELY IMAGED. NO ACUTE INTRACRANIAL PATHOLOGY.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Acute change in mental status. Eyes deviated to the right. Evaluate\n for bleed.\n\n COMPARISON: Comparison is made to prior head CT from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a bilobed CSF density lesion posterior to the left\n cerebellar hemisphere which has been previously described and has imaging\n characteristics consistent with a giant cisterna magna. This is unchanged.\n There is global brain atrophy. There is hypodensity in the periventricular\n white matter consistent with chronic microvascular ischemic change. There are\n no major vascular territorial infarcts. There is no intracranial hemorrhage.\n\n There is a fluid density lesion located in the subcutaneous tissues anterior\n to the subcutaneous tissues just below the nose related to the upper lip.\n There is destruction of a portion of the anterior wall of the left maxillary\n sinus and the anterior portions of the hard palate. This lesion is\n incompletely imaged and was not included in the field of view on the prior\n head CT. However, this was present on MRI and is unchanged in\n size since that time.\n\n IMPRESSION: No acute intracranial pathology. Destructive lesion involving the\n anterior hard palate and left maxillary sinus which is incompletely imaged but\n appears unchanged in size since the MRI from . This may\n represent an infectious source such as a peridental abscess. Clinical\n correlation is suggested and correlation with physical exam is suggested.\n Additional imaging of the facial bones could be considered to better\n characterize the location and characteristics of this lesion.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-12-17 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 812051, "text": " 8:23 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: SZ, UNRESPONSIVE, MASS IN PALATE ON CT\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with ?sz now unresponsive\n REASON FOR THIS EXAMINATION:\n r/o mass, please obtain cuts through palate mass seen on CT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unresponsive with question of seizure. Assess nasal mass seen on\n prior CT.\n\n COMPARISON: Head CT and ; brain MRI ,.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted gadolinium-enhanced MR of the brain\n with susceptibility.\n\n FINDINGS: There is a moderate amount of brain atrophy. Diffuse increased\n FLAIR signal in the periventricular white matter areas and punctate increased\n FLAIR signal in the subcortical white matter areas is likely related to\n chronic microvascular infarction. There is no evidence of abnormal\n susceptibility artifact to suggest intracranial hemorrhage. There is no mass\n effect, shift of normally midline structures, or hydrocephalus. There is\n fluid within the mastoid air cells bilaterally.\n\n Within the anterior maxilla, there is a 2.9 x 3.5 cm lobulated mass lesion\n which demonstrates heterogeneous, moderately increased T2 signal and which\n does not enhance. This was present on the prior MR study of ,\n but was not included in the field of imaging on the prior CT scan of , . There is no associated high signal within the adjacent bone.\n\n Additional note is made of a 1.7 x 1.3 cm mass within the left parotid gland\n which enhances and likely represents a pleomorphic adenoma, with an intra-\n parotid lymph node being a secondary possibility. This is unlikely to be\n related to the maxillary mass described above.\n\n No other areas of abnormal contrast enhancement are appreciated. Several\n sequences are degraded by patient motion.\n\n IMPRESSION:\n 1. Chronic-appearing, non-enhancing mass within the anterior maxilla. Signal\n intensity of this may represent fluid, as might be found in an incisive canal\n cyst, or it may be cartilaginous in origin, possibly emanating from the nasal\n septum.\n 2. Left parotid gland mass, likely reflecting a pleomorphic adenoma.\n 3. Mastoid fluid bilaterally.\n (Over)\n\n 8:23 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: SZ, UNRESPONSIVE, MASS IN PALATE ON CT\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2116-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812067, "text": " 5:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evalute for masses, infection\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure.\n REASON FOR THIS EXAMINATION:\n evalute for masses, infection\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE AP CHEST:\n\n INDICATION: Seizure.\n\n Since the previous cxr of , there has been placement of an NG tube\n which terminates in the stomach with tip cephalad in the region of the fundus.\n Cardiac and mediastinal contours are within normal limits for portable\n technique. There is a new patchy alveolar opacity in the right perihilar\n region. There may be an additional area of opacity at the left base, as the\n left hemidiaphragm is not as well demonstrated on the prior exam.\n\n IMPRESSION: Patchy right perihilar alveolar opacity and possible additional\n left basilar opacity. In a patient with h/o seizure, aspiration should be\n considered. Infectious pneumonia is also possible.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-12-23 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 812536, "text": " 1:21 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Please aquire DWIs, and T1 w gad and T2 coronals\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with ?sz has PLEDS from left temporal and fluctuating LOC.\n Please evaluate for encephalitis, stroke, or structural abnormalities. Thx\n REASON FOR THIS EXAMINATION:\n Please aquire DWIs, and T1 w gad and T2 coronals\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fluctuating loss of consciousness.\n\n TECHNIQUE: Multiplanar T1 and T2 images of the brain pre contrast, T1 coronal\n images post contrast. Susceptibility, FLAIR, and diffusion-weighted images\n were also obtained. 13 cc of Magnevist was used for this examination.\n\n Comparison is made to .\n\n FINDINGS:\n MRI OF THE BRAIN WITH AND WITHOUT GADOLINIUM:\n\n There is a moderate amount of brain atrophy with widening of the sulci and\n ventricles bilaterally, unchanged from the prior study. FLAIR images\n demonstrate several areas of bilateral punctate increased signal intensity\n within the periventricular white matter consistent with small vessel ischemic\n disease, also unchanged from the prior study. There are no new areas of\n increased signal intensity.\n\n Diffusion-weighted images show no areas of abnormally slowed diffusion.\n Susceptibility images show no areas of abnormal susceptibility artifact to\n suggest acute intracranial hemorrhage. There is no shift of normally midline\n structures noted. There is no abnormal enhancement on post-gadolinium images\n to suggest parenchymal mass. The hippocampi and temporal lobes appear\n symmetric, and are unchanged in appearance from the prior study.\n\n Again is noted a lobulated mass lesion in the anterior maxilla which shows\n increased T2 signal and no enhancement post contrast. This is also unchanged\n in appearance. There is mucosal thickening in the right maxillary sinus.\n\n IMPRESSION: No evidence of acute infarction or intracranial hemorrhage. No\n parenchymal mass lesion is noted on the post-contrast images. Symmetric\n appearance to the hippocampi and temporal lobes without evidence of acute\n encephalitis. Overall, there has been no change in the appearance of the\n brain compared with the study of .\n (Over)\n\n 1:21 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Please aquire DWIs, and T1 w gad and T2 coronals\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2116-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812915, "text": " 11:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check NG tube placementevaluate pneumonia\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure, and confusion. s/p ngt placement\n\n REASON FOR THIS EXAMINATION:\n check NG tube placementevaluate pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80 year old man with seizure and confusion status post NG tube\n placement.\n\n Comparison is made to prior study dated . The tip of the NG tube is in\n the body of the stomach. Right perihilar pulmonary opacity is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812826, "text": " 6:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new ngt placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure, and confusion. s/p ngt placement\n\n REASON FOR THIS EXAMINATION:\n new ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check nasogastric tube placement in patient with seizure and\n confusion.\n\n PORTABLE CHEST: Semi upright view obtained at 6:10 P.M. is compared to study\n from one hour earlier. The distal end of the nasogastric tube is now coiled\n in the stomach with the tip projecting over the left upper quadrant of the\n abdomen. The right perihilar pulmonary opacities shows continued improvement.\n\n IMPRESSION: Nasogastric tube tip in stomach.\n\n" }, { "category": "Radiology", "chartdate": "2116-12-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812494, "text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure.\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizure, ?infiltrate.\n\n Comparison is made to the prior chest x ray on .\n\n SUPINE AP CHEST: There is an NG tube present in stable position. The heart and\n mediastinal contours are unchanged. There has been interval improvement and\n re-expansion of the ill-defined bibasilar patchy opacities. There is again\n noted bilateral rods in the lumbar region.\n\n IMPRESSION: Further clearing of bilateral infiltrate/atelectasis at the lung\n bases.\n\n" }, { "category": "Radiology", "chartdate": "2116-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812387, "text": " 5:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please compare\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure.\n\n REASON FOR THIS EXAMINATION:\n please compare\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Seizure.\n\n A SINGLE AP UPRIGHT VIEW: Comparison: .\n\n The heart shows slight LV enlargement. The pulmonary vessels are within\n normal limits, allowing for posture. There is again evidence of ill-defined\n patchy pulmonary infiltrates/atelecatasis in both lung bases. There is also\n blunting of the left cp angle, suggesting a small effusion. These findings\n could be due to aspiration pneumonitis. An ET tube is noted extending into\n the lower portion of the stomach. Bilateral rods are again noted\n in the lumbar region.\n\n IMPRESSION: The appearances are essentially unchanged since . Bibasilar\n pulmonary infiltrates are noted, consistent with aspiration pneumonitis.\n There is minimal improvement at this time, if any.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812814, "text": " 4:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ngt placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure, and confusion. s/p ngt placement\n\n REASON FOR THIS EXAMINATION:\n eval ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check nasogastric tube placement in patient with seizure and\n confusion.\n\n PORTABLE CHEST: An upright view was obtained at 4:46 P.M. is compared to\n . The nasogastric tube is coiled in the pharynx and in the thoracic\n esophagus. The tip is in the lower cervical esophagus. The right perihilar\n opacities, most likely representing aspiration is not significantly changed.\n The left lung is clear.\n\n IMPRESSION: Coiled nasogastric tube with tip in cervical esophagus.\n\n" }, { "category": "Radiology", "chartdate": "2116-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812258, "text": " 11:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrate\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with seizure.\n\n REASON FOR THIS EXAMINATION:\n eval infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest .\n\n COMPARISON: .\n\n INDICATION: Seizure.\n\n This is a repeat dictation for a previously lost report.\n\n A nasogastric tube remains in place, coiling in the proximal stomach. Cardiac\n silhouette is mildly enlarged but stable. Previously noted right perihilar\n opacity has improved, but there are worsening opacities in the retrocardiac\n portions of both lower lobes and in the left perihilar region. Small left\n pleural effusion is noted.\n\n IMPRESSION: Resolution of right perihilar opacity, but worsening opacities in\n the retrocardiac region of both lower lobes, which could be due to recurrent\n aspiration event in this patient with history of seizures.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-12-22 00:00:00.000", "description": "Report", "row_id": 1373897, "text": "NURSING PROGRESS NOTE 0700-1100\nNEURO--PT MORE ALERT AS THE MORNING PASSES. HE IS AWAKE AND SPEAKS IN INCOMPREHENSIBLE SOUNDS. DOES NOT FOLLOW COMMANDS. MAE SPONT BUT NOT TO COMMAND. EEG LEADS TO COME OFF TODAY. POSSIBLE MRI TOMORROW. NO SEIZURE ACTIVITY NOTICED. ANTISEIZURE DRUG DOSAGE INCREASED.\n\nGI--TOL TUBE FEEDS WITH MIN RESIDUAL. LGR LIQUID STOOL THIS AM.\n\nGU--UO >40 CC HR.\n\nCARDIAC--BP STABLE. K+3.3. RECEIVED 30 MEQ PNGT. TO RECEIVE ADDITIONAL 30 PNTG AND 40MEQ IN 500 CC D5W. PT IS HAVING FREQUENT PVC'S.\n\nRESP--NTS X2 FOR SMALL AMTS OF THICK TAN SPUTUM. NASAL TRUMPET D/CED BECAUSE MUCOUS PLUG WOULD NOT ALLOW FOR CATHETER TO PASS. SAO2 ON HI FLOW 40% 97%.\n\nSKIN--INTACT.\n\nCOPING--NO FAMILY MEMBERS HAVE PHONED THIS AM.\n\nA--MENTAL STATUS IMPROVING FROM EARLIER TODAY.\n\nP==CON'T PULM TOILET. CON'T TO REORIENT AND REDIRECT AS NEEDED. PROVIDE SAFETY TO PT.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-12-22 00:00:00.000", "description": "Report", "row_id": 1373898, "text": "MICU Nursing Progress Note 11a-7p\nNeuro-\nCont to be alert to stimuli, Not FC, MAE, spont speaking garbled words. EEG leads taken off. antisz rx cont. Improved overall. Neuro rec>tegretol levels therapeutic, MRI wed \nResp-\nProbable asp pnx. Cool neb .40 w/ sat 95%, desat to 88-89% on RA. BS-upper clear/course w/ intermittent exp wheezes, lower course, good airiation. CPT bilat given q4-5hr w/ good prod of sputum via nst sx q4h-thick tan. RR 20-23.\nCV-\nStable- 13-150/50's, HR 55-65 NSR;cont on CAD rx.\nFluids/Nut/GI\nImpact w/ fiber @ 70/h=goal, BS+, NT, ND, soft. Small brown stool x3. IVF @ kvo. u/o 50-100/hr. I=2695/O=2360.\nID-\nafebrile, only + cx is of sputum, BC are pending. wbc 12k.\nA/P\ns/p sz event, now improving, more alert, rx given, achieving tx levels tegretol.\nPropable asp pnx, on antibx, afebrile, cont CPT.\nSocial-Family visiting and calling. All updated. Neuro page #given for them to obtain direct info.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-24 00:00:00.000", "description": "Report", "row_id": 1373901, "text": "MICU-B, NPN:\nNeuro: Pt. alert and opening eyes spontaneously throughout shift but unable to follow commands. MAE independently, PERRLA @2mm. Received X1 extra dose Tegretol @ 400mg. Latest head imaging done does not show new findings form . Pt. is verbal but speech is garbled and is not relevant to time/place when comprehensible. Needs to be tranferred OOB to chair.\n\nCV: HR 70's-90's NSR with occ. multi-form PVC's. SBP 110's- 150's. Peripheral pulses are palpalbe.\n\nResp: O2Sats mid-high 90's on 40% humidified mask. De'Sats to mid 80's when removes mask. Lungs are coarse with transient I/E wheezes and diminished @ bases. Very productive cough but is unable tot completely clear upper airway. Attempted to suxn. pt. both oro-pharyngeally and -pharyngeally but pt. very resisitent- combative and biting @ suxn. catheter. Receives CPT during from RN and PT.\n\nHeme/lytes/micro: HIT Ab negative. Afebrile this shift. Tx'd with Vanco./Levo./Falgyl for g- rods to sputum, likely asp. pna. from seizure. Nasal swabs neg. for VRE, MRSA screen pending. CSF cx neg., U cx neg., HSV PCR pending- will cont. Acyclovir until results back.\nStool sent for C.Diff. FSBG qid, cover per RISS.\n\nGI: TF' Impact with fiber @ 70cc/hr are @ goal with minimal residuals. +BS, stooling liquid brown stool into fecal incontinence bag.\n\nGU: Foley to gravity draining clear yellow urine.\n\nDerm: D&I.\n\nSocial: FULL CODE, ? if this is in accordance with pt.'s real wishes per advanced directive in front of chart. Family's goal is to get pt. back to nursing home.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-18 00:00:00.000", "description": "Report", "row_id": 1373887, "text": "NURSING PROGRESS NOTE:\nPT IS AN 80 YR OLD GENTLEMAN WHO WAS ADMITTED TO HOSP WITH SEIZURES AND MENTAL STATUS CHG'S.\nPT ARRIVED FROM UNRESPONSIVE AND NOT MOVING ANY EXTREMETIES. PUPILS EQUAL AND REACTIVE. WHEN TURNING PT HE BEGAN TO OPEN EYES AND BLINK, AND SLOWLY BEGAN TO MOVE HIS LEFT ARM AND LEG. PT STILL UNABLE TO SPEAK. GRADUALLY WOULD LOOK AT YOU WHEN YOU CALLED OUT HIS NAME. UNABLE TO MOVE RIGHT SIDE AT FIRST, THEN AS NIGHT WORE ON HE BEGAN TO MOVE RIGHT ARM AND RIGHT LEG ON THE BED. MOVING LEFT SIDE NORMALLY WITH GOOD STRENGTH. PT'S GAG REFLEX ABSENT. NGT INSERTED WITHOUT ANY RESPONSE TO GAG REFLEX. HAS PRETTY GOOD COUGH REFLEX.\nCV: PT IS NSR 80-90 WITHOUT ECTOPY. BP INITIALLY IN THE 170'S BUT SETTLED DOWN TO THE 140'S. RESP RATE IN THE TEENS. TEMP 99.8 PO/RECT.\nRESP: INITIALLY ON SIMPLE O2 MASK WITH O2 SAT 99-100% THIS WAS CHG'D TO 5L NASAL CANULA. O2 SAT'S IN THE HIGHT 90'S. LUNG SOUNDS CLEAR BUT HAS A CONGESTED COUGH.\nGI: NGT PLACED, PT NPO. ABD SOFT NON TENDER WITH BOWEL SOUNDS PRESENT.NO STOOL DURING THE NIGHT.\nGU: FOLEY CATH DRAINING LRG AMT'S OF PALE YELLOW URINE. IV FLUID CHG'D TO D51/2NS WITH 20KCL AT 80/HR.\nSKIN: INTACT BUT DRY. HAS SOME RED SPOTS ON CHEST AREA.\nLP DONE BY RESIDENT. FLUID CLEAR, OPENING PRESSURE 25 THEN SETTLED DOWN TO 14. SPEC SENT.\nPT SEEN BY HIS OWN PHYSICIAN ON ARRIVAL TO THE UNIT. PT IS FULL CODE.\nWHILE IN THE PT HAD HEAD CT AND MRI DONE WHICH SHOWED MASS ON UPPER PALATE. PT TO START ON UNASYN AFTER ID APPROVAL. WBC 18.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-12-18 00:00:00.000", "description": "Report", "row_id": 1373888, "text": "Nursing Process Note: 0700-1900\nNEURO: Alert, nonverbal this shift though verbal at baseline. Eyes open but does not follow commands. Pupils reactive bilat. EEG done showing some sz activity though no overt signs noted. Given additional Valproate IV and Tegretol PO doses this shift as well as increase in sched. doses. Able to move left arm with purposful movt and some movt noted at right arm as shift progressed. Moving both legs. Soft wrist restraint left hand to maintain integrity of lines.\n\nRESP: CXR showing opacities consistent with asp PNA; congested cough, nonproductive. High flow humidified O2 to maintain sats >90%. Chest PT done and NTS for mod amt yellow, thick sputum. LS coarse throughout. Sats consisently low 90s. RR in 20s.\n\nC/V: HR 90s, no ectopy. BP 110s/50-60s. Receiving D5 1/2 NS with 20K @ 80hr cont.\n\nGI: NPO. Abdomen soft, present sounds. No BM this shift. NGT in place, patent for PO meds. Placement checked via auscultation.\n\nGU: Foley patent for cyu; quantities sufficient.\n\nENDO: FSQID, covered with SS insulin.\n\nID: Tmax 103 rectally; received Tylenol with some effect. Receiving Unasyn IV; CT scan revealed mass at palate/sinus; evaluated by ENT.\n\nSOCIAL: Son and dtr in to visit; very pleasant and supportive. Son is health care proxy-numbers in front of chart.\n\nPLAN: Monitor temp, resp status, neuro status\n EEG in room for overnight monitoring\n NPO\n IV maintenance fluids\n IV Abx\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-12-19 00:00:00.000", "description": "Report", "row_id": 1373891, "text": "Nursing Addendum: 0700-1900\nValproic Acid level = 35; MD will write additional orders.\nPotassium = 3.2; gave Kcl 40MEQ via NGT at 1830.\nPlease send trough Valproic acid level in AM.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-12-20 00:00:00.000", "description": "Report", "row_id": 1373892, "text": "MICU-B, NPN:\nNeuro: Pt. non-verbal until end of shift when made attempts to speak but mostly mouthing words/incpmprehensible speech. PERRLA @ 3mm, Moves RUE, LUE, RLE on bed but no movement noted to LLE. EEG done approx. q 90 minutes this shift. Gave total extra 750mg Valproic acid. Trough pending. Discussed possibility of HSV encephalitis with house staff, ? MRI for difinitive dx.\n\nCV: HR 90's NSR w/o ectopy. SBP 130's-150's. Palpable peripherals. Team asked for IVF D51/2 to be d/c'd d/t increasing coarseness of lung sounds. Plan is to place better IV access.\n\nResp: O2Sats mid 90's on 60% Hi-flow mask. de'Sat's X1 to mid 80's but responded well to suxn'ing. RT rec'd. mucomyst- written for nebs but would like to use it as irrigant. Lungs are coarse througout, increasingly diminished @ R base. ? team to place A-line to follow ABG's.\n\nHeme/lytes/micro: Afebrile this shift. Receiving Acyclovir for ? HSV encephalitis. Clinda for pna. All cx's NGTD. Please send C.-diff. when possible.\n\nGI: NPO. ? start TF's today. + BS, no BM.\n\nGU: Foley to gravity draining amber clear urine.\n\nDerm: D&I.\n\nSocial: FULL CODE. Family involved.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-20 00:00:00.000", "description": "Report", "row_id": 1373893, "text": "Nursing Process Note: 0700-1900\nNEURO: Increased interaction/movt beginning of shift. Arousable to verbal/tactile stim. Still not following commands as mental status remains relatively unchanged. Continuing with EEG recordings. Pupils 3mm/brisk bilat. Valproic Acid dose decreased-level=54. Tegretol=8.5.\n\nRESP: Continues on 50% humidified face mask. LS coarse. Sats mid to high 90s. CPT done with varying success; able to NTS for mod amt thick, yellow sputum early in shift. RR spontaneously increases to >30 with no change in sats.\n\nC/V: HR <100 consistently. BP 130-140s/60s. IVF d/c'd; KVO only. Pulses easily palpable. Repleted with IV KPhos for Phos 1.3\n\nGI: Started TF Impact with fiber; currently @ 20cc/hr toward goal of 85cc/hr. Abdomen soft, present sounds.\n\nGU: Foley patent for amber urine; quantities sufficient.\n\nENDO: Covered with SS insulin\n\nID: Afebrile; receiving IV Clinda, acyclovir, Cef.\n\nSOCIAL: Family in; given update by SICU team.\n\nPLAN: Increase TF Q4 hrs for goal 85cc/hr. Next advance .\n Monitor resp status\n Follow up with chem sent at 1830\n EEG recording\n" }, { "category": "Nursing/other", "chartdate": "2116-12-22 00:00:00.000", "description": "Report", "row_id": 1373896, "text": "NPN NOcs:\n Nuero: See careview for specifics. MAE. opens eyes to voice. does not follow commands. words garbled. No seizure activity.\n ID: tmax 101. HO notified. blood cx and UA sent as ordered. CXR done. tylenol given. on Acyclovir/Clinda.\n rESP: requiring frequent sx later in shift for thick tan secretions. Sats high 90's. rr 20's. LS intermittently course. cpt done lightly x 2. remains on 40% hiflow neb. recieved albuterol neb x 1 for wheezing.\n CV: sbp 130's-140's. HR 70's80's with pvc's. On lisinopril and atenolol.\n GU: UO 40-100.\n GI: tf's at max. no residual. no stool.\n endo: fsbs requiring ss coverage x 1.\n A/P: pt with temp spike o/n. Neuro status essentially unchanged. requiring frequent pulmonary toilet. plan is for 1 more eeg this am, then eeg to be dc'd.\n" }, { "category": "ECG", "chartdate": "2116-12-17 00:00:00.000", "description": "Report", "row_id": 161303, "text": "Poor quality tracing. T wave inversions in leads II, III and aVF. ST segment\ndepressions in leads V3-V6. INT: Non-specific ST-T wave abnormalities. Ischemia\nis in the differential diagnosis. Compared to the previous tracing of \nsinus rhythm was clearly previously present. Likely sinus rhythm persists, but\nbaseline prevents accurate diagnosis. Please repeat. T wave abnormalities were\npreviously present. Anterolateral ST segment depressions have newly appeared.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-12-19 00:00:00.000", "description": "Report", "row_id": 1373889, "text": "MICU-B, NPN:\nNeuro: Pt. alert, opens eyes spontaneously, PERRLA @ 3mm, moves RUE, LUE, and RLE spontaneoudly- no spontaneous movement noted to LLE. Attempting to speak but sounds mostly incomprehensible. Tracks with eyes, seems to know name. EEG done q 1 hr X 1 min. No obvious signs of seizure activity. Given extra dose 500mg IV for Valproic acid d/t low therapeutic level last p.m.\n\nCV: HR low 100's- 120's ST w/o ectopy. SBP 120's-150's. Easily palpable peripherals.\n\nResp: O2Sats mid-high 90's on 100% face tent. Spontaneously de Sats to mid 80's. Does not respond to CPT d/t resistance to suctioning. Face tent replaced with face mask @ 100%. Nasal trumpet placed to R nare by RT to facilitate suctioning. Pt. has very poor cough. Lungs are coarse throughout.\n\nHeme/lytes/micro: T-max 102.8 rectally. Blood cx's X2 sent, urine cx sent. No labs ordered for this a.m. ORL following for ? tx of palatal mass- rec.'s are for outpt. tx. Antbx coverage includes Unasyn.\n\nGI: NPO. Nutrition rec.'s starting TF's. No BM. +BS.\n\nGU: Foley to gravity draining clear amber urine.\n\nDerm: D&I.\n\nSocial: FULL CODE. Family involved.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-19 00:00:00.000", "description": "Report", "row_id": 1373890, "text": "Nursing Process Note: 0700-1900\nNEURO: Less interactive than previously noted from . Not following commands and not tracking. Pupils reactive/brisk bilat 3mm. Moving left arm and leg; withdrawing to nailbed pressure. Some jaw twitching noted correlating with increased RR >30; gave Ativan 0.5mg IV as ordered for abnormal facial movt. EEG activity not conclusive for seizures as stated by neuro. Continue to record activity Qhr.\n\nRESP: LS continue coarse; NTS for moderate amt blood tinged sputum-culture sent. No gag or cough. RR spontaneously increases to >30 though sats remain mid to high 90s. ABG 7.44/40/149; O2 titrated down to 60%.\n\nID: Continues with increased temp; Tmax 103.2 rectally. Receiving Tylenol fairly regularly with minimal effect. Unasyn d/c'd; started Ceftriaxone, Clindamycin, Acyclovir. Bld/urine/sputum cx PND.\n\nC/V: HR low 100s; started Atenolol, Lisinopril, and Lopressor PRN for HR >100. SBPs one teens up to 160.\n\nGI: NPO. Meds via NGT. Abdomen soft, present sounds. No BM this shift. Past hx of C-Diff, placed on contact precautions. Family states ruled negative at nursing home.\n\nGU: Foley patent for amber urine; quantities sufficient.\n\nENDO: Covered with ss insulin.\n\nSOCIAL: Lives at nsg home; family very supportive/involved and knowledgable re: tx/meds.\n\nDISPO: Full code\n\nPLAN: Lopressor IV for HR>100 (Q6hr PRN)\n IV ABX\n Stool for C-diff\n EEG record Q hr\n Monitor temp/APAP PRN\n FSBS QID\n" }, { "category": "Nursing/other", "chartdate": "2116-12-21 00:00:00.000", "description": "Report", "row_id": 1373894, "text": "MICU-B, NPN:\nNeuro: Pt. waxes/wanes. Aroused to voice but unresponsive verbally and withdrawing only from noxious stimuli. PERRLA @ 3mm. EEG done approx. q 90 minutes. More alert following events such as nasopharyngeal suxn'ing/bathing/blood draws. ? verbally responsive to noxious stimuli this a.m.\n\nCV: HR 80's-90's NSR wo/o ectopy. SBP 100's-150's. Easily palpable peripherals. Peripheral IV's d/c'd- able to replace with 18g X 1 to R ant. forearm.\n\nResp: O2Sats high 90's on 50% face mask. Spontaneously de'Sats to mid 80's- responds positively to aggressive suxn'ing via nasal trumpet. Able to suxn. very copious thick tan sputum from what sounds like upper airway. Very poor cough, impaired gag. Receives CPT from PT. LUngs sound coarse throughout. ABG this a.m. 7.46, 43, 81.\n\nHeme/lytes/micro: HIT Ab sent d/t plaetlet ct. 51 this a.m. K+ 3.4 repleted with 60 mEq KCl. Hung 40mEq KCl in 500cc but d/c'd @ 5:00 d/t K+ 4.4 with a.m. labs. Mg 1.8 repleted with 2g MgSo4, Mg this a.m. 2.4. Afebrile. Clinda., Ceftaz. for asp. pnx. Acyclovir for ? HSV encephalopathy.\n\nGI: Impact with fiber advanced to 60cc hr with minimal residuals via NGT to L nare. Goal is 80cc/hr. +BS, no BM.\n\nGU: Foley to gravity draining clear yellow urine.\n\nDerm: D&I.\n\nSocial: FULL CODE. Family involved.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-21 00:00:00.000", "description": "Report", "row_id": 1373895, "text": "FULL CODE Universal Precautions Allergy: Dilantin\n\n\nNeuro: Occ opens eyes spont, occ to name. Not following commands. Moving upper extrems spont - L better than R; will move R leg spont/stim, but L leg will move with deep stim. Minimal cough reflex - will cough when NT sx cath is completely inserted. No gag reflex. Occ grunts. Pt has not received any sedation. No further EEG testing and it will be removed by EEG tomorrow. EEGs were inconclusive per neuro team. Valproic acid and tegretol doses changed.\n\nCardiac: HR=60-80s, NSR w/ Occ PACs. BP=130-150/60s. +perpiph pulses, no edema, extrems cool. On Lisinopril and Atenelol.\n\nResp: 40% FM w/ 02 sat 96-98%. Suctioning less secretions via nasal trumpet as the day went on - still thick,tan. Maintained 02 sat well thru-out the day. BS coarse prior to sx at times, but then cleared. CPT done.\n\nGI/GU: Abd soft, +BS, no BM. TF Impact w/ fiber at goal = 70cc/hr w/ minimal resids (20cc). Pepcid d/c'd and started on protonix. Foley cath w/ clear yellow urine.\n\nOther: Does not appear to be in any discomfort. Skin intact\n\nAntibx: febrile. On clindamycin, ceftriaxone and acyclovir\n\nSocial: Spoke to son on phone this am and Daughter was in to visit this afternoon.\n\nLabs: FS=150s - covered by ISSC; HIT antibodies negative.\n\nPlan: Continue to monitor neuro/cardiac/resp status. Monitor labs - rx as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-23 00:00:00.000", "description": "Report", "row_id": 1373899, "text": "MICU-B, NPN:\nNeuro: Spontaneously alert, opening eyes with periods of agitation- swings legs over siderails. Frequent incomprehensible speech with occasional clear, brief statements like, \"Don't do that.\" PERRLA @ 2mm, MAE independently but leans towards L side.Prelim. results of cont. EEG shows PLEDS, or indicator of subcortical abnormality as per team. Pt. does have chronic bony cyst above upper palate in mouth- ORL examined and determined it could be addressed as outpt. ? MRI today.\n\nCV: HR 70's-90's NSR with occ. multi-form PVC's. SBP 120's-150's, easily palpable peripheral pulses. ? EF 30%.\n\nResp: Lungs are coarse upper lobes, diminished @ bases. O2Sats mid 90's on 40% Hi-flow humidified mask. Does not always clear own secretions well, requires nasopharyngeal suxn'ing.\n\nHeme/lytes/micro: Afebrile this shift. Grew g neg. rods to sputum , tx'd for asp. pna. Acyclovir for ? HSV encephalopathy. Team added on HSV PCR to CSF taken . MRSA/VRE screen sent. Has h/o C.Diff. FSBG qid.\n\nGI: TF's Impact with fiber @ 70cc/hr with minimal residuals. +BS. Fecal incontinence bag applied- stool is OB neg.\n\nGU: Foley to gravity draining claer yellow urine. Goal is to keep pt. euvolemic.\n\nDerm: D&I.\n\nSocial: FULL CODE but advanced directive is in chart. Pt. signed statement indicating that he would not want measures taken to prolong his life should he be remain in a vegetative state w/o hope of recovery.\n" }, { "category": "Nursing/other", "chartdate": "2116-12-23 00:00:00.000", "description": "Report", "row_id": 1373900, "text": "Nursing Process Note: 0700-1900\nNEURO: Intermittent periods of increased movt/garbled speech alternating with periods of lethargy. Does not follow commands. MAE, purposeful movt toward face mask. Sent for MRI today; neuro team questioning additional sz activity. Received total of 3mg Ativan IV during MRI.\n\nC/V: Held Atenolol for SBP <110. Will reasses before end of shift. HR 80s, no ectopy.\n\nRESP: Ineffective cough, receiving CPT by RN and PT. NTS for thick, tan sputum, blood tinged sputum; difficult entering airway. Sats remaine mid 90s on 40% Hum face mask. LS coarse bilat.\n\nGI: Abdomen soft, nondist. Liquid brn stool sent for C-diff today. TF Impact with fiber at goal rate of 71cc/hr via NGT.\n\nGU: Foley patent for CYU.\n\nID: Afebrile this shift. Receiving Levo/Vanco/Acyclovir.\n\nENDO: Covered with SS insulin.\n\nSOCIAL: Family in to visit; encouraged by ability to speak some words.\n\nDISPO: Full code; continues to be ICU patient secondary to frequent resp needs.\n\nPLAN: Tegretol dose increased; needs to receive total of 800mg today; please give 200mg at this eve then back to normal dosing.\n EEG ordered\n Freq pulmonary assessment\n IV/PO ABX\n" } ]

[ { "category": "Nursing", "chartdate": "2105-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356034, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 29,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology consult\n Response:\n Pending am HCT-30.0\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, to have\n cystoscopy on Wed, transfuse as needed.\n Hypotension (not Shock)\n Assessment:\n SBP at 70\ns when asleep and 100\ns when awake. Patient is known for low\n blood pressures as outpatient. Team aware\nGiven that the patient is a\n dialysis patient with severe PVD the wide pulse pressure is expected.\n HR 80\ns-100\ns Afib. No peripheral edema.\n Action:\n 500cc NS bolus given, transfused w/ 1 unit\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns hemodynamic status, trend Hct, IVF bolus\n prn if needed however need to be limited given that the patient is\n dialysis dependent.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcers on bil heels, coccyx, and RT calf. Coccyx wound appears\n to be stage 2 heels and calf stage 4.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels where cleaned w/normal saline and dressed\n w/deoderm gel, wet to moist dressing. Both heels have some slough\n tissue at the wound base. Calf wound appears to be clean w/granulating\n tissue. Bone seen at the base of the wound. The wound was cleaned\n w/normal saline, deoderm gel applied and covered w/wet to dry dressing.\n Both feet elevated on the pillows.\n Response:\n pending\n Plan:\n Continue to monitor skin integrity, wound care consult, specialty bed??\n plastics consult if worsening\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n GI: abd soft distended, positive for BS, no BM this shift, denies\n nausea, vomiting.\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Generic Note", "row_id": 356398, "text": "TITLE:\n 79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Transfused\n on with dialysis crit 25.2\n Action:\n Received from OR at 19 30 hrs post Cystoscopy & transurethral resection\n of Bladder Tumor. Biopsy sent.\n Response:\n Labs done at 1 am as per orders, hct ^ed to 30.\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, Monitor\n for bleeding.\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels cleaned w/normal saline and dressed w/deoderm\n gel, wet to moist dressing. Both heels have some slough tissue at the\n wound base. Calf wound appears to be clean w/granulating tissue. Bone\n seen at the base of the wound. The wound was cleaned w/normal saline,\n deoderm gel applied and covered w/wet to dry dressing. Both feet\n elevated on the pillows. Waiting for vasc. Recs Per vascular a wound\n vac will be applied to right calf wound tomorrow\n Response:\n pending\n Plan:\n Continue to monitor skin integrity, Wound vac application today.\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema. Bp\n cuff on the left forearm near the wrist.\n GI: abd soft distended, positive for BSt, denies nausea, vomiting.\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2105-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356347, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Transfused\n to day with dialysis crit 25.2\n Action:\n On call to OR awaiting cystoscopy\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns status, follow up urology recs,\n cystoscopy in am, transfuse as needed. Needs crit post procedure\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels where cleaned w/normal saline and dressed\n w/deoderm gel, wet to moist dressing. Both heels have some slough\n tissue at the wound base. Calf wound appears to be clean w/granulating\n tissue. Bone seen at the base of the wound. The wound was cleaned\n w/normal saline, deoderm gel applied and covered w/wet to dry dressing.\n Both feet elevated on the pillows. Waiting for vasc. Recs Per\n vascular a wound vac will be applied to right calf wound tomorrow\n Response:\n pending\n Plan:\n Continue to monitor skin integrity,\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema.\n GI: abd soft distended, positive for BS, BMx1 this shift, denies\n nausea, vomiting. NPO starting MN\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Physician ", "chartdate": "2105-12-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 356471, "text": "Chief Complaint: Anemia, hypotension, vaginal bleeding, chronic renal\n failure.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient had cystoscopy with bx of bladder mass. Tumor felt to be\n eroding into wall of bladder.\n Afebrile.\n 24 Hour Events:\n OR SENT - At 05:30 PM\n OR RECEIVED - At 07:30 PM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:26 AM\n Other medications:\n Vit B, renagel, lipitor, insulin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (98.9\n HR: 81 (67 - 98) bpm\n BP: 116/29(49) {107/29(49) - 157/77(90)} mmHg\n RR: 22 (15 - 25) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 175 mL\n 889 mL\n PO:\n 50 mL\n 780 mL\n TF:\n IVF:\n 40 mL\n 109 mL\n Blood products:\n 85 mL\n Total out:\n 360 mL\n 0 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 889 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : Anterior and lateral)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Trace edema, Left: Trace, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 10.2 g/dL\n 269 K/uL\n 92 mg/dL\n 2.8 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 15 mg/dL\n 108 mEq/L\n 143 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n 12:46 AM\n 04:09 AM\n WBC\n 11.3\n 6.9\n 6.7\n 10.1\n 9.4\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n 30.8\n 30.1\n Plt\n 73\n 269\n Cr\n 3.6\n 4.3\n 2.8\n Glucose\n 94\n 86\n 105\n 92\n Other labs: PT / PTT / INR:13.4/27.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %, Ca++:7.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ANEMIA\n BLADDER MASS\n Awaiting path on bladder biopsies. Hct stable. Not at transfusion\n threshold. Small amount of blood in Foley catheter.\n Hemodynamically stable. No recurrent hypotension.\n Electrolytes and acid-base status acceptable. Dialysis due tomorrow.\n ICU Care\n Nutrition: oral\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not applicable.\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25\n" }, { "category": "Nursing", "chartdate": "2105-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356230, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 23.8,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology following\n Response:\n Pending am HCT\n Plan:\n Continue to monitor patient\ns status, follow up urology recs,\n cystoscopy in am, transfuse as needed.\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels where cleaned w/normal saline and dressed\n w/deoderm gel, wet to moist dressing. Both heels have some slough\n tissue at the wound base. Calf wound appears to be clean w/granulating\n tissue. Bone seen at the base of the wound. The wound was cleaned\n w/normal saline, deoderm gel applied and covered w/wet to dry dressing.\n Both feet elevated on the pillows. Waiting for vasc. recs\n Response:\n pending\n Plan:\n Continue to monitor skin integrity, wound care consult, specialty bed??\n plastics consult if worsening, vasc consult\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema.\n GI: abd soft distended, positive for BS, BMx1 this shift, denies\n nausea, vomiting. NPO starting MN\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Generic Note", "row_id": 356442, "text": "TITLE:\n 79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Paient had pain post op- 5mg Oxycodone given with good relief. No\n complains of pain till time noted.\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Transfused\n on with dialysis crit 25.2 patient has red colored urine via 2\n way urinary cathetrer which was inserted in the OR.\n Action:\n Received from OR at hrs post Cystoscopy & transurethral resection\n of Bladder Tumor. Biopsy sent.\n Response:\n Labs done at 1 am as per orders, hct ^ed to 30 repeat hct in am lab\n stable at 30\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, Monitor\n for bleeding. As MD , to keep foley in for couple of days.\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx. Has mild pedal edema.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels cleaned w/normal saline and dressed w/deoderm\n gel, wet to moist dressing. Both heels have some slough tissue at the\n wound base. Calf wound appears to be clean w/granulating tissue. Bone\n seen at the base of the wound. The wound was cleaned w/normal saline,\n deoderm gel applied and covered w/wet to dry dressing. Both feet\n elevated on the pillows. Waiting for vasc. Recs Per vascular a wound\n vac will be applied to right calf wound tomorrow\n Response:\n No new changes noted in skin condition.\n Plan:\n Continue to monitor skin integrity, Wound vac application today.\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema. Bp\n cuff on the left forearm near the wrist.\n GI: abd soft distended, positive for BSt, denies nausea, vomiting.\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Physician ", "chartdate": "2105-12-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356445, "text": "Chief Complaint: Hypotension, bleeding\n 24 Hour Events:\n Pt underwent cystoscopy with partial removal of tumor, which was said\n to invade bladder wall. Pathology report pending\n -Gave oxycodone 5 q 4 PRN for pain\n Vascular surgery contact regarding LE wounds; plan for VAC dressing\n today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Denies chest pain, abdominal pain, SOB.\n Thirsty/Hungry, no other complaints\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 91 (67 - 98) bpm\n BP: 107/60(73) {107/34(56) - 157/77(90)} mmHg\n RR: 21 (15 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 175 mL\n 375 mL\n PO:\n 50 mL\n 300 mL\n TF:\n IVF:\n 40 mL\n 75 mL\n Blood products:\n 85 mL\n Total out:\n 360 mL\n 0 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN: pleasant, NAD\n HEENT: PERRL, MMM, OP with petecia on small palette and apparent\n denture irritation, otherwise clear.\n CV: rrr, no murmurs appreciated\n PULM: CTAB\n ABD: +BS, soft, nt, nd.\n EXT: bilateral le dressed with gauze, diminished pedal pulses\n bilaterally\n NEURO: A+O x3, moves all extremities.\n Labs / Radiology\n 269 K/uL\n 10.2 g/dL\n 92 mg/dL\n 2.8 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 15 mg/dL\n 108 mEq/L\n 143 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n 12:46 AM\n 04:09 AM\n WBC\n 11.3\n 6.9\n 6.7\n 10.1\n 9.4\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n 30.8\n 30.1\n Plt\n 73\n 269\n Cr\n 3.6\n 4.3\n 2.8\n Glucose\n 94\n 86\n 105\n 92\n Other labs: PT / PTT / INR:13.4/27.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %, Ca++:7.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-12-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356450, "text": "Chief Complaint: Hypotension, bleeding\n 24 Hour Events:\n Pt underwent cystoscopy with partial removal of tumor, which was said\n to invade bladder wall. Pathology report pending\n -Gave oxycodone 5 q 4 PRN for pain\n Vascular surgery contact regarding LE wounds; plan for VAC dressing\n today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Denies chest pain, abdominal pain, SOB.\n Thirsty/Hungry, no other complaints\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 91 (67 - 98) bpm\n BP: 107/60(73) {107/34(56) - 157/77(90)} mmHg\n RR: 21 (15 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 175 mL\n 375 mL\n PO:\n 50 mL\n 300 mL\n TF:\n IVF:\n 40 mL\n 75 mL\n Blood products:\n 85 mL\n Total out:\n 360 mL\n 0 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 375 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN: pleasant, NAD\n HEENT: PERRL, MMM, OP with petecia on small palette and apparent\n denture irritation, otherwise clear.\n CV: rrr, no murmurs appreciated\n PULM: CTAB\n ABD: +BS, soft, nt, nd.\n EXT: bilateral le dressed with gauze, diminished pedal pulses\n bilaterally, no C/C/E\n NEURO: A+O x3, moves all extremities.\n Labs / Radiology\n 269 K/uL\n 10.2 g/dL\n 92 mg/dL\n 2.8 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 15 mg/dL\n 108 mEq/L\n 143 mEq/L\n 30.1 %\n 9.4 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n 12:46 AM\n 04:09 AM\n WBC\n 11.3\n 6.9\n 6.7\n 10.1\n 9.4\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n 30.8\n 30.1\n Plt\n 73\n 269\n Cr\n 3.6\n 4.3\n 2.8\n Glucose\n 94\n 86\n 105\n 92\n Other labs: PT / PTT / INR:13.4/27.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding.\n .\n # Bleeding/Bladder mass: S/p cystoscopy yesterday. No evidence of\n bleeding since procedure. HCT stable; biopsy now pending.\n - f/u with urology\n - await path findings\n # Tachycardia/hypotension: Resolved. Felt to secondary to blood loss\n which is now stable.\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n # PVD/LE Ulcers: Followed by vascular surgery. Will come by today to\n place VAC dressing to the wound.\n - follow-up vascular recs\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Betablockers and diuretics initially held on arrival.\n - consider adding Carvediolol 12.5 and Furosemide 60 mg ,tu,th,sa\n per home regimen.\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point.\n # FEN: Lyte repletion PRN (Mg low this AM), Dialysis per renal\n schedule.\n - follow-up renal recs.\n ICU Care\n Nutrition: Renal diet\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT: SQ heparin, penumoboots\n Stress ulcer: none\n Code status: Full code\n Disposition: transfer to surgery\n" }, { "category": "Nursing", "chartdate": "2105-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356246, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 23.8,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology following\n Response:\n Pending am HCT -25.1\n Plan:\n Continue to monitor patient\ns status, follow up urology recs,\n cystoscopy in am, transfuse as needed.\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels where cleaned w/normal saline and dressed\n w/deoderm gel, wet to moist dressing. Both heels have some slough\n tissue at the wound base. Calf wound appears to be clean w/granulating\n tissue. Bone seen at the base of the wound. The wound was cleaned\n w/normal saline, deoderm gel applied and covered w/wet to dry dressing.\n Both feet elevated on the pillows. Waiting for vasc. recs\n Response:\n pending\n Plan:\n Continue to monitor skin integrity, wound care consult, specialty bed??\n plastics consult if worsening, vasc consult\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema.\n GI: abd soft distended, positive for BS, BMx1 this shift, denies\n nausea, vomiting. NPO starting MN\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2105-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356007, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 29,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology consult\n Response:\n Pending am HCT-30.0\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, to have\n cystoscopy on Wed, transfuse as needed.\n Hypotension (not Shock)\n Assessment:\n SBP at 70\ns when asleep and 100\ns when awake. Patient is known for low\n blood pressures as outpatient. Team aware\nGiven that the patient is a\n dialysis patient with severe PVD the wide pulse pressure is expected.\n HR 80\ns-100\ns Afib. No peripheral edema.\n Action:\n 500cc NS bolus given, transfused w/ 1 unit\n Response:\n Pending\n Plan:\n Continue to monitor patient\ns hemodynamic status, trend Hct, IVF bolus\n prn if needed however need to be limited given that the patient is\n dialysis dependent.\n Impaired Skin Integrity\n Assessment:\n Pressure ulcers on bil heels, coccyx, and RT calf. Coccyx wound appears\n to be stage 2 heels and calf stage 4.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels where cleaned w/normal saline and dressed\n w/deoderm gel, wet to moist dressing. Both heels have some slough\n tissue at the wound base. Calf wound appears to be clean w/granulating\n tissue. Bone seen at the base of the wound. The wound was cleaned\n w/normal saline, deoderm gel applied and covered w/wet to dry dressing.\n Both feet elevated on the pillows.\n Response:\n pending\n Plan:\n Continue to monitor skin integrity, wound care consult, specialty bed??\n plastics consult if worsening\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n GI: abd soft distended, positive for BS, no BM this shift, denies\n nausea, vomiting.\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Physician ", "chartdate": "2105-12-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 356124, "text": "Chief Complaint: vaginal bleeding\n HPI:\n This is a 79 year-old female with a history of PVD, AF, who presents\n with vaginal bleeding. The patient reports being in her usual state of\n health until this AM when she started to bleed. Per report the patient\n had ongoing vaginal bleeding with passing large clots that persisted\n throughout the day. Given her recent diagnosis of a fungating bladder\n mass, the patient was seen by urology in the emergency room. Given\n that she had blood loss and mild hypotension while in the ER, the\n decision was made by the urology and ER teams to admit her to the ICU.\n Of note the patient was recently admitted to the vascular service and\n found to have a fungating bladder mass in evaluation. During the\n admission, the patient was seen by gyn and urology. Since discharge\n the patient was seen by urology as an outpatient and a cystoscopy was\n attempted without success.\n .\n In the ED, initial vitals were T 97 BP 109/54 HR 112, RR 16 02 97% RA.\n Patient was reportedly seen by urology and is to be admitted to the\n for evaluation of the bleeding.\n On arrival to the floor the patient was asymptomatic including no\n dizziness, no lightheadeness, no fever, chills or chest pain.\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity edema,\n cough, urinary frequency, urgency, dysuria, lightheadedness, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME Medications:\n Albuterol \n Aspirin 81 mg daily\n Atorvastatin 10 mg daily\n Brimodine\n Carvediolol 12.5 \n Furosemide 60 mg ,tu,th,sa\n Insulin sliding scale\n metoclopramide\n micanazole\n mvi\n scopolamine\n sevelamer 800 TID\n Vit B\n Percocet 1 tab this PM\n Past medical history:\n Family history:\n Social History:\n 1. PVD with Right Lower Extremity non-healing ulcers, recent admission\n for debridement\n 2. hypercholesterolemia\n 3. ESRD on HD\n 4. atrial fibrillation\n 5. DM\n 6. depression\n 7. hypothyroidism\n 8. Bladder mass\n 9. Constipation\n 10. Anemia\n N/C\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Has daughter and son, smoked 1 ppd <10 yrs, stopped 8 years ago,\n lives alone but currently at , HCPs are son \n ) and daughter ()\n Review of systems:\n Constitutional: No(t) Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Edema\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 04:18 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 88 (88 - 111) bpm\n BP: 82/43(50) {82/34(50) - 117/54(65)} mmHg\n RR: 21 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 10 mL\n 892 mL\n PO:\n TF:\n IVF:\n 10 mL\n 542 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 10 mL\n 892 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, pale\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Trace, Left: Trace, RLE with large ulcer, well\n granulated tissue without purulent drainage or erythematous skin\n changes surrounding. Mild tenderness. Bilateral skin lesions on foot,\n necrotic areas, warm extremities but with faint pulses.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 262 K/uL\n 9.0 g/dL\n 29.0 %\n 11.3 K/uL\n [image002.jpg]\n \n 2:33 A12/16/ 12:24 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n Hct\n 29.0\n Plt\n 262\n Imaging: CT abdomen: Preliminary Report !! WET READ !!\n Extensive hemorrhage in the urinary bladder along with a known bladder\n cancer which has grown in size. Air in the bladder in the absence of a\n urinary \n is worrisome for invasion into the cervix or vagina. Multiple stable\n pancreatic cystic lesions, can be further assesed by non-emergent MRCP.\n CXR:\n FINDINGS: The heart is enlarged, unchanged from the prior examination.\n The lungs are clear. There is no evidence to suggest a left-sided\n pneumothorax. There is stable atherosclerosis in the thoracic aorta.\n CONCLUSION: Stable cardiomegaly with clear lungs\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding\n .\n # Vaginal bleeding: Based on history the patient was reported to lose a\n significant amount of blood. Initial repeat hct stable at 29.\n Nonetheless, the patient has ongoing blood loss, hypotension and\n intermittent tachycardia. Based on CT scan the patient has eroding\n bladder mass that is causing bleeding.\n - transfused 1 U\n - repeat hct\n - follow up urology recs, to have cystoscopy on Wed\n .\n # Tachycardia/hypotension: Tachcardia improving with blood, hypotension\n likely secondary to blood loss, though the patient with low blood\n pressures as outpatient. Other potential causes could include\n infection, anxiety, pain. Given that the patient is a dialysis patient\n with severe PVD the wide pulse pressure is expected.\n - trend hct\n - tx 1 U\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n .\n # Bladder cancer: Diagnosed this year, seen by urology recently and\n unable to complete a cystoscopy. There is not a tissue diagnosis at\n this point and the patient does not have any recollection that she has\n a bladder cancer.\n - urology to do cystoscopy\n - support blood volume as above\n .\n # PVD/ s/p debridement: wound appears to be healing with good\n granulation tissue and minimal evidence for infection. Will have wound\n care evaluate the patient in AM. Will consider plastics consult if\n worsening. Holding aspirin for now given\n .\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Given the patient's hypotension, will not add betablockers\n at this time, but will add back when bleeding stable. Not currently on\n anticoagulation\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point and diabetic diet.\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2105-12-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356272, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 05:14 PM\n - Urology - npo mn, plan for proecedure\n - PICC line placed\n - Renal - HD tommorow, ? PRBC during HD (per ICU team)\n - Hct - 29 > 30 (s/p 1 UPRBC) > 24.1 > 23.8 > 25.1 (post-transfusion 1\n u prbc)\n - Anesthesia contact re: procedure and aware of pt for tommorow's\n procedure\n - Vascular contact and aware of pt (no official consult requested)\n - 1.44 second sinus pause on telemetry (astymptomatic) o/n\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 75 (70 - 100) bpm\n BP: 106/33(49) {81/26(42) - 115/59(67)} mmHg\n RR: 22 (18 - 29) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 2,304 mL\n 85 mL\n PO:\n TF:\n IVF:\n 1,689 mL\n Blood products:\n 615 mL\n 85 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 248 K/uL\n 8.4 g/dL\n 86 mg/dL\n 4.3 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 25.1 %\n 6.7 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n WBC\n 11.3\n 6.9\n 6.7\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n Plt\n \n Cr\n 3.6\n 4.3\n Glucose\n 94\n 86\n Other labs: PT / PTT / INR:13.2/29.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-12-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356274, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 05:14 PM\n - Urology - npo mn, plan for proecedure\n - PICC line placed\n - Renal - HD tommorow, ? PRBC during HD (per ICU team)\n - Hct - 29 > 30 (s/p 1 UPRBC) > 24.1 > 23.8 > 25.1 (post-transfusion 1\n u prbc)\n - Anesthesia contact re: procedure and aware of pt for tommorow's\n procedure\n - Vascular contact and aware of pt (no official consult requested)\n - 1.44 second sinus pause on telemetry (astymptomatic) o/n\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 75 (70 - 100) bpm\n BP: 106/33(49) {81/26(42) - 115/59(67)} mmHg\n RR: 22 (18 - 29) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 2,304 mL\n 85 mL\n PO:\n TF:\n IVF:\n 1,689 mL\n Blood products:\n 615 mL\n 85 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Labs / Radiology\n 248 K/uL\n 8.4 g/dL\n 86 mg/dL\n 4.3 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 25.1 %\n 6.7 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n WBC\n 11.3\n 6.9\n 6.7\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n Plt\n \n Cr\n 3.6\n 4.3\n Glucose\n 94\n 86\n Other labs: PT / PTT / INR:13.2/29.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding.\n .\n # Vaginal bleeding: Based on history the patient was reported to lose a\n significant amount of blood. Initial repeat hct stable at 29\n yesterday, but then given one unit for HCT 23.8, now bumped to 25.1.\n Based on CT scan the patient has eroding bladder mass that is causing\n bleeding.\n - PM HCT\n -Patient to have cystoscopy today.\n # Tachycardia/hypotension: Tachcardia improving with blood, hypotension\n likely secondary to blood loss, though the patient with low blood\n pressures as outpatient. Other potential causes could include\n infection, anxiety, pain. Given that the patient is a dialysis patient\n with severe PVD the wide pulse pressure is expected.\n - trend hct\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n .\n # Bladder cancer: Diagnosed this year, seen by urology recently and\n unable to complete a cystoscopy. There is not a tissue diagnosis at\n this point and the patient does not have any recollection that she has\n a bladder cancer.\n - urology to do cystoscopy\n - support blood volume as above\n .\n # PVD/ s/p debridement: wound appears to be healing with good\n granulation tissue and minimal evidence for infection. Will have wound\n care evaluate the patient in AM. Will consider plastics consult if\n worsening. Holding aspirin for now given\n .\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Given the patient's hypotension, will not add betablockers\n at this time, but will add back when bleeding stable. Not currently on\n anticoagulation\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point and diabetic diet.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-12-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356275, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 05:14 PM\n - Urology - npo mn, plan for proecedure\n - PICC line placed\n - Renal - HD tommorow, ? PRBC during HD (per ICU team)\n - Hct - 29 > 30 (s/p 1 UPRBC) > 24.1 > 23.8 > 25.1 (post-transfusion 1\n u prbc)\n - Anesthesia contact re: procedure and aware of pt for tommorow's\n procedure\n - Vascular contact and aware of pt (no official consult requested)\n - 1.44 second sinus pause on telemetry (astymptomatic) o/n\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36\nC (96.8\n HR: 75 (70 - 100) bpm\n BP: 106/33(49) {81/26(42) - 115/59(67)} mmHg\n RR: 22 (18 - 29) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 2,304 mL\n 85 mL\n PO:\n TF:\n IVF:\n 1,689 mL\n Blood products:\n 615 mL\n 85 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, pale\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Trace, Left: Trace, RLE with large ulcer, well\n granulated tissue without purulent drainage or erythematous skin\n changes surrounding. Mild tenderness. Bilateral skin lesions on foot,\n necrotic areas, warm extremities but with faint pulses.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 248 K/uL\n 8.4 g/dL\n 86 mg/dL\n 4.3 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 25.1 %\n 6.7 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n WBC\n 11.3\n 6.9\n 6.7\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n Plt\n \n Cr\n 3.6\n 4.3\n Glucose\n 94\n 86\n Other labs: PT / PTT / INR:13.2/29.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding.\n .\n # Vaginal bleeding: Based on history the patient was reported to lose a\n significant amount of blood. Initial repeat hct stable at 29\n yesterday, but then given one unit for HCT 23.8, now bumped to 25.1.\n Based on CT scan the patient has eroding bladder mass that is causing\n bleeding.\n - PM HCT\n -Patient to have cystoscopy today.\n # Tachycardia/hypotension: Tachcardia improving with blood, hypotension\n likely secondary to blood loss, though the patient with low blood\n pressures as outpatient. Other potential causes could include\n infection, anxiety, pain. Given that the patient is a dialysis patient\n with severe PVD the wide pulse pressure is expected.\n - trend hct\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n .\n # Bladder cancer: Diagnosed this year, seen by urology recently and\n unable to complete a cystoscopy. There is not a tissue diagnosis at\n this point and the patient does not have any recollection that she has\n a bladder cancer.\n - urology to do cystoscopy\n - support blood volume as above\n .\n # PVD/ s/p debridement: wound appears to be healing with good\n granulation tissue and minimal evidence for infection. Will have wound\n care evaluate PND. Will consider plastics consult if worsening.\n Holding aspirin for now given\n .\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Given the patient's hypotension, will not add betablockers\n at this time, but will add back when bleeding stable. Not currently on\n anticoagulation\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point and diabetic diet.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2105-12-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 355985, "text": "Chief Complaint: vaginal bleeding\n HPI:\n This is a 79 year-old female with a history of PVD, AF, who presents\n with vaginal bleeding. The patient reports being in her usual state of\n health until this AM when she started to bleed. Per report the patient\n had ongoing vaginal bleeding with passing large clots. She then went\n to dialysis but continued to have bleeding. She then went to the ER\n with this ongoing bleeding\n .\n In the ED, initial vitals were T 97 BP 109/54 HR 112, RR 16 02 97% RA.\n Patient was reportedly seen by urology and is to be admitted to the\n for evaluation of the bleeding.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity edema,\n cough, urinary frequency, urgency, dysuria, lightheadedness, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME Medications:\n Albuterol \n Aspirin 81 mg daily\n Atorvastatin 10 mg daily\n Brimodine\n Carvediolol 12.5 \n Furosemide 60 mg ,tu,th,sa\n Insulin sliding scale\n metoclopramide\n micanazole\n mvi\n scopolamine\n sevelamer 800 TID\n Vit B\n Percocet 1 tab this PM\n Past medical history:\n Family history:\n Social History:\n 1. PVD with Right Lower Extremity non-healing ulcers, recent admission\n for debridement\n 2. hypercholesterolemia\n 3. ESRD on HD\n 4. atrial fibrillation\n 5. DM\n 6. depression\n 7. hypothyroidism\n 8. Bladder CA\n 9. Constipation\n 10. Anemia\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Has daughter and son, smoked 1 ppd, stopped 8 years ago, lives\n alone but currently at , HCPs are son ) and\n daughter ()\n Review of systems:\n Constitutional: No(t) Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Edema\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 04:18 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 88 (88 - 111) bpm\n BP: 82/43(50) {82/34(50) - 117/54(65)} mmHg\n RR: 21 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 10 mL\n 892 mL\n PO:\n TF:\n IVF:\n 10 mL\n 542 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 10 mL\n 892 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, pale\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 262 K/uL\n 9.0 g/dL\n 29.0 %\n 11.3 K/uL\n [image002.jpg]\n \n 2:33 A12/16/ 12:24 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n Hct\n 29.0\n Plt\n 262\n Imaging: CT abdomen: Preliminary Report !! WET READ !!\n Extensive hemorrhage in the urinary bladder along with a known bladder\n cancer which has grown in size. Air in the bladder in the absence of a\n urinary \n is worrisome for invasion into the cervix or vagina. Multiple stable\n pancreatic cystic lesions, can be further assesed by non-emergent MRCP.\n CXR:\n FINDINGS: The heart is enlarged, unchanged from the prior examination.\n The lungs are clear. There is no evidence to suggest a left-sided\n pneumothorax. There is stable atherosclerosis in the thoracic aorta.\n CONCLUSION: Stable cardiomegaly with clear lungs\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding\n .\n # Vaginal bleeding: Based on history the patient was reported to lose a\n significant amount of blood. Initial repeat hct stable at 29.\n Nonetheless, the patient has ongoing blood loss, hypotension and\n intermittent tachycardia. Based on CT scan the patient has eroding\n bladder mass that is causing bleeding.\n - transfuse 1 U\n - repeat hct in AM\n - follow up urology recs, to have cystoscopy on Wed\n .\n # Tachycardia/hypotension: Tachcardia improving with blood, hypotension\n likely secondary to blood loss, though the patient with low blood\n pressures as outpatient. Other potential causes could include\n infection, anxiety, pain. Given that the patient is a dialysis patient\n with severe PVD the wide pulse pressure is expected.\n - trend hct\n - tx 1 U\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n .\n # Bladder cancer:\n .\n # PVD/ s/p debridement: wound appears to be healing with good\n granulation tissue and minimal evidence for infection. Will have wound\n care evaluate the patient in AM. Will consider plastics consult if\n worsening. Holding aspirin for now given\n .\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Given the patient's hypotension, will not add betablockers\n at this time, but will add back when bleeding stable. Not currently on\n anticoagulation\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point and diabetic diet.\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2105-12-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 355987, "text": "Chief Complaint: vaginal bleeding\n HPI:\n This is a 79 year-old female with a history of PVD, AF, who presents\n with vaginal bleeding. The patient reports being in her usual state of\n health until this AM when she started to bleed. Per report the patient\n had ongoing vaginal bleeding with passing large clots. She then went\n to dialysis but continued to have bleeding. She then went to the ER\n with this ongoing bleeding\n .\n In the ED, initial vitals were T 97 BP 109/54 HR 112, RR 16 02 97% RA.\n Patient was reportedly seen by urology and is to be admitted to the\n for evaluation of the bleeding.\n .\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity edema,\n cough, urinary frequency, urgency, dysuria, lightheadedness, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME Medications:\n Albuterol \n Aspirin 81 mg daily\n Atorvastatin 10 mg daily\n Brimodine\n Carvediolol 12.5 \n Furosemide 60 mg ,tu,th,sa\n Insulin sliding scale\n metoclopramide\n micanazole\n mvi\n scopolamine\n sevelamer 800 TID\n Vit B\n Percocet 1 tab this PM\n Past medical history:\n Family history:\n Social History:\n 1. PVD with Right Lower Extremity non-healing ulcers, recent admission\n for debridement\n 2. hypercholesterolemia\n 3. ESRD on HD\n 4. atrial fibrillation\n 5. DM\n 6. depression\n 7. hypothyroidism\n 8. Bladder CA\n 9. Constipation\n 10. Anemia\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Has daughter and son, smoked 1 ppd, stopped 8 years ago, lives\n alone but currently at , HCPs are son ) and\n daughter ()\n Review of systems:\n Constitutional: No(t) Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Edema\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 04:18 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 88 (88 - 111) bpm\n BP: 82/43(50) {82/34(50) - 117/54(65)} mmHg\n RR: 21 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 10 mL\n 892 mL\n PO:\n TF:\n IVF:\n 10 mL\n 542 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 10 mL\n 892 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, pale\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 262 K/uL\n 9.0 g/dL\n 29.0 %\n 11.3 K/uL\n [image002.jpg]\n \n 2:33 A12/16/ 12:24 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n Hct\n 29.0\n Plt\n 262\n Imaging: CT abdomen: Preliminary Report !! WET READ !!\n Extensive hemorrhage in the urinary bladder along with a known bladder\n cancer which has grown in size. Air in the bladder in the absence of a\n urinary \n is worrisome for invasion into the cervix or vagina. Multiple stable\n pancreatic cystic lesions, can be further assesed by non-emergent MRCP.\n CXR:\n FINDINGS: The heart is enlarged, unchanged from the prior examination.\n The lungs are clear. There is no evidence to suggest a left-sided\n pneumothorax. There is stable atherosclerosis in the thoracic aorta.\n CONCLUSION: Stable cardiomegaly with clear lungs\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding\n .\n # Vaginal bleeding: Based on history the patient was reported to lose a\n significant amount of blood. Initial repeat hct stable at 29.\n Nonetheless, the patient has ongoing blood loss, hypotension and\n intermittent tachycardia. Based on CT scan the patient has eroding\n bladder mass that is causing bleeding.\n - transfuse 1 U\n - repeat hct in AM\n - follow up urology recs, to have cystoscopy on Wed\n .\n # Tachycardia/hypotension: Tachcardia improving with blood, hypotension\n likely secondary to blood loss, though the patient with low blood\n pressures as outpatient. Other potential causes could include\n infection, anxiety, pain. Given that the patient is a dialysis patient\n with severe PVD the wide pulse pressure is expected.\n - trend hct\n - tx 1 U\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n .\n # Bladder cancer: Diagnosed this year, seen by urology recently and\n unable to complete a cystoscopy. There is not a tissue diagnosis at\n this point and the patient does not have any recollection that she has\n a bladder cancer.\n - urology to do cystoscopy\n - support blood volume as above\n .\n # PVD/ s/p debridement: wound appears to be healing with good\n granulation tissue and minimal evidence for infection. Will have wound\n care evaluate the patient in AM. Will consider plastics consult if\n worsening. Holding aspirin for now given\n .\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Given the patient's hypotension, will not add betablockers\n at this time, but will add back when bleeding stable. Not currently on\n anticoagulation\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point and diabetic diet.\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2105-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356187, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 29,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology consult\n Response:\n am HCT-30.0 then 24.1 then 23.8\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, to have\n cystoscopy on Wed, transfuse as needed.\n Hypotension (not Shock)\n Assessment:\n SBP at 70\ns when asleep and 100\ns when awake. Patient is known for low\n blood pressures as outpatient. Team aware\nGiven that the patient is a\n dialysis patient with severe PVD the wide pulse pressure is expected.\n HR 80\ns-100\ns Afib. No peripheral edema.\n Action:\n PICC line placed by IV team and comfirmed by chest x-ray ok to use,\n bolused with 1 liter of ns earlier today\n Response:\n Bp labile all day\n Plan:\n Continue fluid boluses if needed\n" }, { "category": "Nursing", "chartdate": "2105-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356188, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 29,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology consult\n Response:\n am HCT-30.0 then 24.1 then 23.8\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, to have\n cystoscopy on Wed, transfuse as needed.\n Hypotension (not Shock)\n Assessment:\n SBP at 70\ns when asleep and 100\ns when awake. Patient is known for low\n blood pressures as outpatient. Team aware\nGiven that the patient is a\n dialysis patient with severe PVD the wide pulse pressure is expected.\n HR 80\ns-100\ns Afib. No peripheral edema.\n Action:\n PICC line placed by IV team and comfirmed by chest x-ray ok to use,\n bolused with 1 liter of ns earlier today\n Response:\n Bp labile all day\n Plan:\n Continue fluid boluses if needed\n Per wound care\n" }, { "category": "Nursing", "chartdate": "2105-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356193, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 29,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology consult\n Response:\n am HCT-30.0 then 24.1 then 23.8\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, to have\n cystoscopy on Wed, transfuse as needed.\n Hypotension (not Shock)\n Assessment:\n SBP at 70\ns when asleep and 100\ns when awake. Patient is known for low\n blood pressures as outpatient. Team aware\nGiven that the patient is a\n dialysis patient with severe PVD the wide pulse pressure is expected.\n HR 80\ns-100\ns Afib. No peripheral edema.\n Action:\n PICC line placed by IV team and comfirmed by chest x-ray ok to use,\n bolused with 1 liter of ns earlier today\n Response:\n Bp labile all day\n Plan:\n Continue fluid boluses if needed\n Per wound care nurse she felt that coccyx area was more of a perineal\n dermatitis vs. a stage 2 decub. And legs and heels ahe is leaving up\n to the vascular team for recs. See wound care nurses note in careweb\n NPO after midnighr for cystoscopt/biosy in am.\n" }, { "category": "Physician ", "chartdate": "2105-12-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 356299, "text": "Chief Complaint: Anemia, bladder mass, hypotension, chronic renal\n failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Hemodynamically stable with volume resuscitation.\n Transfused 1 unit PRBCs - hct rose from 24 to 25.\n 24 Hour Events:\n PICC LINE - START 05:14 PM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n vitamin B, insulin, lipitor, heparin sc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.7\nC (98\n HR: 87 (70 - 100) bpm\n BP: 132/53(74) {81/26(42) - 132/63(74)} mmHg\n RR: 25 (18 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 2,304 mL\n 85 mL\n PO:\n TF:\n IVF:\n 1,689 mL\n Blood products:\n 615 mL\n 85 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,304 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : Anterior and lateral, No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: ), Good air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Trace edema, Left: Trace, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, and time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.4 g/dL\n 248 K/uL\n 86 mg/dL\n 4.3 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 28 mg/dL\n 101 mEq/L\n 134 mEq/L\n 25.1 %\n 6.7 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n 01:06 PM\n 05:26 PM\n 04:07 AM\n WBC\n 11.3\n 6.9\n 6.7\n Hct\n 29.0\n 30.0\n 24.1\n 23.8\n 25.1\n Plt\n \n Cr\n 3.6\n 4.3\n Glucose\n 94\n 86\n Other labs: PT / PTT / INR:13.2/29.6/1.1, Differential-Neuts:85.8 %,\n Lymph:7.3 %, Mono:5.8 %, Eos:0.6 %, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ANEMIA\n Blood pressue improved with fluids. Hct stable although not rising as\n much as one would expect with transfusion. Due for surgery today.\n On dialysis now. Electrolytes and acid-base status stable.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:04 PM\n PICC Line - 05:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 25 minutes\n" }, { "category": "Physician ", "chartdate": "2105-12-01 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 356083, "text": "Chief Complaint: Blood loss, anemia, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Bladder mass diagnosed during last hospitalization when patient was\n being evaluated for vaginal bleeding. Cystoscopy was unsuccessful.\n Yesterday, developed vaginal bleeding. Went to ED after her dialysis.\n Vaginal bleeding is felt to be due to erosion of bladder mass into\n vagina.\n In MICU, patient dropped BP with tachycardia and then with drop in HR.\n Patient was mentating well. Vascular access was difficult. Given\n fluids. Transfused with 1 unit of PRBCs. Hemodynamics stabilized.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Peripheral vasc disease - s/p fem- bypass; arterial ulcers\n CRF on dialysis\n Afib\n Hypothyroid\n Bladder tumor\n DM\n Occupation:\n Drugs:\n Tobacco: Distant\n Alcohol:\n Other: Lives at \n Review of systems:\n Flowsheet Data as of 09:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 95 (88 - 111) bpm\n BP: 108/54(66) {77/34(46) - 117/54(66)} mmHg\n RR: 20 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 10 mL\n 943 mL\n PO:\n TF:\n IVF:\n 10 mL\n 593 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 10 mL\n 943 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube, oral mucosa dry\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ),\n Few rales that clear with cough\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place time, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 262 K/uL\n 30.0 %\n 9.0 g/dL\n 3\n 19\n 32\n 99\n 4.7\n 140\n 11.3 K/uL\n [image002.jpg]\n 12:24 AM\n 05:04 AM\n WBC\n 11.3\n Hct\n 29.0\n 30.0\n Plt\n 262\n Other labs: Mg++:1.9, PO4:4.3\n Imaging: CXR: normal heart size. No infiltrates or effusions\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ANEMIA\n Patient's hemodynamics stable overnight following fluids and red cell\n transfusion. Bleeding per vagina has diminished. No evidence of acute\n cardiac event. No signs of sepsis. If necessary, would give additional\n fluid today; oxygenation stable. Patient being dialyzed M/W/F.\n Patient's hypotension associated with sleeping.\n Electrolytes and acid-base status stable.\n Patient to be assessed for diagnosis and therapy by urology.\n To be started on sc heparin for DVT prophylaxis.\n ICU Care\n Nutrition: oral\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 11:04 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments: Not applicable\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2105-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356263, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 23.8,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology following\n Response:\n Pending am HCT -25.1\n Plan:\n Continue to monitor patient\ns status, follow up urology recs,\n cystoscopy in am, transfuse as needed.\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels where cleaned w/normal saline and dressed\n w/deoderm gel, wet to moist dressing. Both heels have some slough\n tissue at the wound base. Calf wound appears to be clean w/granulating\n tissue. Bone seen at the base of the wound. The wound was cleaned\n w/normal saline, deoderm gel applied and covered w/wet to dry dressing.\n Both feet elevated on the pillows. Waiting for vasc. recs\n Response:\n pending\n Plan:\n Continue to monitor skin integrity, wound care consult, specialty bed??\n plastics consult if worsening, vasc consult\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema.\n GI: abd soft distended, positive for BS, BMx1 this shift, denies\n nausea, vomiting. NPO starting MN\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Physician ", "chartdate": "2105-12-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 356074, "text": "Chief Complaint: vaginal bleeding\n HPI:\n This is a 79 year-old female with a history of PVD, AF, who presents\n with vaginal bleeding. The patient reports being in her usual state of\n health until this AM when she started to bleed. Per report the patient\n had ongoing vaginal bleeding with passing large clots that persisted\n throughout the day. Given her recent diagnosis of a fungating bladder\n mass, the patient was seen by urology in the emergency room. Given\n that she had blood loss and mild hypotension while in the ER, the\n decision was made by the urology and ER teams to admit her to the ICU.\n Of note the patient was recently admitted to the vascular service and\n found to have a fungating bladder mass in evaluation. During the\n admission, the patient was seen by gyn and urology. Since discharge\n the patient was seen by urology as an outpatient and a cystoscopy was\n attempted without success.\n .\n In the ED, initial vitals were T 97 BP 109/54 HR 112, RR 16 02 97% RA.\n Patient was reportedly seen by urology and is to be admitted to the\n for evaluation of the bleeding.\n On arrival to the floor the patient was asymptomatic including no\n dizziness, no lightheadeness, no fever, chills or chest pain.\n ROS: The patient denies any fevers, chills, weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, shortness of breath, orthopnea, PND, lower extremity edema,\n cough, urinary frequency, urgency, dysuria, lightheadedness, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME Medications:\n Albuterol \n Aspirin 81 mg daily\n Atorvastatin 10 mg daily\n Brimodine\n Carvediolol 12.5 \n Furosemide 60 mg ,tu,th,sa\n Insulin sliding scale\n metoclopramide\n micanazole\n mvi\n scopolamine\n sevelamer 800 TID\n Vit B\n Percocet 1 tab this PM\n Past medical history:\n Family history:\n Social History:\n 1. PVD with Right Lower Extremity non-healing ulcers, recent admission\n for debridement\n 2. hypercholesterolemia\n 3. ESRD on HD\n 4. atrial fibrillation\n 5. DM\n 6. depression\n 7. hypothyroidism\n 8. Bladder CA\n 9. Constipation\n 10. Anemia\n N/C\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Has daughter and son, smoked 1 ppd, stopped 8 years ago, lives\n alone but currently at , HCPs are son ) and\n daughter ()\n Review of systems:\n Constitutional: No(t) Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Edema\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 04:18 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 88 (88 - 111) bpm\n BP: 82/43(50) {82/34(50) - 117/54(65)} mmHg\n RR: 21 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 60 Inch\n Total In:\n 10 mL\n 892 mL\n PO:\n TF:\n IVF:\n 10 mL\n 542 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 10 mL\n 892 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, pale\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 262 K/uL\n 9.0 g/dL\n 29.0 %\n 11.3 K/uL\n [image002.jpg]\n \n 2:33 A12/16/ 12:24 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.3\n Hct\n 29.0\n Plt\n 262\n Imaging: CT abdomen: Preliminary Report !! WET READ !!\n Extensive hemorrhage in the urinary bladder along with a known bladder\n cancer which has grown in size. Air in the bladder in the absence of a\n urinary \n is worrisome for invasion into the cervix or vagina. Multiple stable\n pancreatic cystic lesions, can be further assesed by non-emergent MRCP.\n CXR:\n FINDINGS: The heart is enlarged, unchanged from the prior examination.\n The lungs are clear. There is no evidence to suggest a left-sided\n pneumothorax. There is stable atherosclerosis in the thoracic aorta.\n CONCLUSION: Stable cardiomegaly with clear lungs\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HYPOTENSION (NOT SHOCK)\n IMPAIRED SKIN INTEGRITY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assesment: This is a 79 year-old female with a history of PVD, bladder\n cancer, a fib, ESRD who presents with persistent vaginal bleeding\n .\n # Vaginal bleeding: Based on history the patient was reported to lose a\n significant amount of blood. Initial repeat hct stable at 29.\n Nonetheless, the patient has ongoing blood loss, hypotension and\n intermittent tachycardia. Based on CT scan the patient has eroding\n bladder mass that is causing bleeding.\n - transfuse 1 U\n - repeat hct in AM\n - follow up urology recs, to have cystoscopy on Wed\n .\n # Tachycardia/hypotension: Tachcardia improving with blood, hypotension\n likely secondary to blood loss, though the patient with low blood\n pressures as outpatient. Other potential causes could include\n infection, anxiety, pain. Given that the patient is a dialysis patient\n with severe PVD the wide pulse pressure is expected.\n - trend hct\n - tx 1 U\n - IVF bolus prn (though would prefer not to give boluses unless needed\n given that the patient is dialysis dependent).\n .\n # Bladder cancer: Diagnosed this year, seen by urology recently and\n unable to complete a cystoscopy. There is not a tissue diagnosis at\n this point and the patient does not have any recollection that she has\n a bladder cancer.\n - urology to do cystoscopy\n - support blood volume as above\n .\n # PVD/ s/p debridement: wound appears to be healing with good\n granulation tissue and minimal evidence for infection. Will have wound\n care evaluate the patient in AM. Will consider plastics consult if\n worsening. Holding aspirin for now given\n .\n # Atrial fibrillation: patient is rate controlled without meds\n currently. Given the patient's hypotension, will not add betablockers\n at this time, but will add back when bleeding stable. Not currently on\n anticoagulation\n .\n # Diabetes: patient reports having diet controlled diabetes. Will give\n patient insulin sliding scale at this point and diabetic diet.\n .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 11:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2105-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356186, "text": "79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Hct at 29,\n mild bloody stains on the peri pads.\n Action:\n 1 unit of RBC transfused, urology consult\n Response:\n am HCT-30.0 then 24.1 then 23.8\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, to have\n cystoscopy on Wed, transfuse as needed.\n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Generic Note", "row_id": 356413, "text": "TITLE:\n 79 year-old female with a history of PVD, bladder cancer, a fib, ESRD\n who presents with persistent vaginal bleeding\n Vaginal bleeding\n Assessment:\n Vaginal bleeding per report w/lg clots. Based on CT scan from ED the\n patient has eroding bladder mass that is causing bleeding. Transfused\n on with dialysis crit 25.2 patient has red colored urine via 2\n way urinary cathetrer which was inserted in the OR.\n Action:\n Received from OR at hrs post Cystoscopy & transurethral resection\n of Bladder Tumor. Biopsy sent.\n Response:\n Labs done at 1 am as per orders, hct ^ed to 30 repeat hct in am lab\n stable at 30\n Plan:\n Continue to monitor patient\ns status, follow up urology recs, Monitor\n for bleeding. As MD , to keep foley in for couple of days.\n Impaired Skin Integrity\n Assessment:\n Ulcers on bil heels and RT calf and what seems like dermatitis per\n wound care nurse on the coccyx. Has mild pedal edema.\n Action:\n Coccyx was cleaned and moisture barrier applied. Patient repositioned\n on her side. Bil heels cleaned w/normal saline and dressed w/deoderm\n gel, wet to moist dressing. Both heels have some slough tissue at the\n wound base. Calf wound appears to be clean w/granulating tissue. Bone\n seen at the base of the wound. The wound was cleaned w/normal saline,\n deoderm gel applied and covered w/wet to dry dressing. Both feet\n elevated on the pillows. Waiting for vasc. Recs Per vascular a wound\n vac will be applied to right calf wound tomorrow\n Response:\n No new changes noted in skin condition.\n Plan:\n Continue to monitor skin integrity, Wound vac application today.\n Neuro: alert oriented, follows commands, and ambulates w/walker at\n baseline.\n Resp: on 2 L NC w/sats at 98-100%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P at 90-110\ns/40 Hr at 60-90\ns afib. No peripheral edema. Bp\n cuff on the left forearm near the wrist.\n GI: abd soft distended, positive for BSt, denies nausea, vomiting.\n GU: per patient\ns report essentially anuric. On HD M_W_F. RT AV shunt.\n IV access: 2 PIV 20G, LT PICC 2 lumen, AV shunt for HD.\n Social: patient is a FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356512, "text": "Impaired Skin Integrity\n Assessment:\n pt. was seen by vascular and the plan was for vat placement this am,\n but machine not available. pt. has 2 heel ulcers. Both drsgs changed\n this am. Also noted to have several small open areas on , which\n was assessed by the skin nurse yesterday, but are now open and\n draining. Noted to have a black pinpoint area on left finger from\n fingersticks.\n Action:\n Allevyn drsg to . Heels stage 2 and calf stage 4.\n pt. does c/o discomfort at the site of the stage 2 on .\n Turned.\n Response:\n When off site, pain is relieved.\n Plan:\n Plan for vat placement tomorrow. By vascular. Need to assess this\n finger.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Creat 2.8 this am. Cont. on renal diet. c/o being itchy. Pt. c/o being\n thirsty.\n Bs\ns covered with ssi. K+ 4.6. foley in place-small amts of urine.\n Action:\n + bruit (right fistula). Iv kvo d/c\n Response:\n Hemodynamically stable.\n Plan:\n Hemo tomorrow. Cont. on renagel.\n Problem - Description In Comments\n Assessment:\n Pt. was transfused on for a hct of 25.2. post tx and or hcts have\n remained at 30. urine is blood-tinged. Foley in place. No further\n vaginal bleeding noted.\n Action:\n No c/o pain. Temp 98.9-99.1 today. Wbc\ns improved. No c/o abd pain.\n Response:\n Bleeding resolved.\n Plan:\n Continue foley. observe for clots and increased bleeding.\n Pmh: niddm, hx of pvd, hx of atrial fib. Hypercholesteremia. ESRD on\n hemodialysis. Hx of bladder ca. hx of depression. Hx of anemia and\n constipation. s/p smoker for 10yrs. Quit 8 yrs ago. NKA . MRSA/VRE.\n PRESENT ILLNESS: pt. came to the ed from , where she\nd been a\n patient for 1 week for vacular issues. Pt. had developed vaginal\n bleeding and was hypotensive on adm. To the ed. . Pt. was seen by\n urology and underwent a cystoscopy with partial removal of tumor which\n was found to be invading the bladder wall. Sections sent for pathology.\n Pt. transf from the or for further management.\n NEURO: alert and orientated. Wants to go back to . They\n been notified by the case management and they are coming in to screen\n her again. Nervous about not getting out before the storm tomorrow.\n Pt. w as screened-no bed til tomorrow. Pt. is aware.\n GI: + bs\ns . good appetite.\n CV : restarted on coreg at noon, and her lasix which is ordered for\n 16pm. Pt. in at fib rate in 80\ns. hypotension resolved with fluids and\n blood.\n Access: double picc placed when admitted, as unable to place triple\n lumens. In the ed.\n Pulm: bs\ns clear. Sats 100% on ra. Dry coug productive.\n Social: son into visit.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n BLADDER CA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 75.1 kg\n Daily weight:\n 78.7 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral , HEMO or PD, Renal Failure, Smoker\n CV-PMH: Arrhythmias, PVD\n Additional history: 1. PVD with Right Lower Extremity non-healing\n ulcers\n 2. hypercholesterolemia\n 3. ESRD on HD\n 4. atrial fibrillation\n 5. DM\n 6. depression\n 7. hypothyroidism\n 8. Bladder CA\n 9. Constipation\n 10. Anemia\n Surgery / Procedure and date: -cystocopy--partial removal of\n bladder tumor\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:31\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,425 mL\n 24h total out:\n 175 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 04:09 AM\n Potassium:\n 4.6 mEq/L\n 04:09 AM\n Chloride:\n 108 mEq/L\n 04:09 AM\n CO2:\n 25 mEq/L\n 04:09 AM\n BUN:\n 15 mg/dL\n 04:09 AM\n Creatinine:\n 2.8 mg/dL\n 04:09 AM\n Glucose:\n 92 mg/dL\n 04:09 AM\n Hematocrit:\n 30.1 %\n 04:09 AM\n Finger Stick Glucose:\n 170\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu/sicu\n Transferred to: 1280R\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356492, "text": "Impaired Skin Integrity\n Assessment:\n pt. was seen by vascular and the plan was for vat placement this am,\n but machine not available. pt. has 2 heel ulcers. Both drsgs changed\n this am. Also noted to have several small open areas on , which\n was assessed by the skin nurse yesterday, but are now open and\n draining. Noted to have a black pinpoint area on left finger from\n fingersticks.\n Action:\n Allevyn drsg to .\n Response:\n Plan:\n Plan for vat placement tomorrow. By vascular. Need to assess this\n finger.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Creat 2.8 this am. Cont. on renal diet. c/o being itchy. Pt. c/o being\n thirsty.\n Bs\ns covered with ssi. K+ 4.6. foley in place-small amts of urine.\n Action:\n + bruit (right fistula).\n Response:\n Hemodynamically stable.\n Plan:\n Hemo tomorrow.\n Problem - Description In Comments\n Assessment:\n Pt. was transfused on for a hct of 25.2. post tx and or hcts have\n remained at 30. urine is blood-tinged. Foley in place. No further\n vaginal bleeding noted.\n Action:\n No c/o pain.\n Response:\n Plan:\n Continue foley. observe for clots and increased bleeding.\n Pmh: niddm, hx of pvd, hx of atrial fib. Hypercholesteremia. ESRD on\n hemodialysis. Hx of bladder ca. hx of depression. Hx of anemia and\n constipation.\n PRESENT ILLNESS: pt. came to the ed from , where she\nd been a\n patient for 1 week for vacular issues. Pt. had developed vaginal\n bleeding and was hypotensive on adm. To the ed. . Pt. was seen by\n urology and underwent a cystoscopy with partial removal of tumor which\n was found to be invading the bladder wall. Sections sent for pathology.\n Pt. transf from the or for further management.\n NEURO: alert and orientated. Wants to go back to . They\n been notified by the case management and they are coming in to screen\n her again. Nervous about not getting out before the storm tomorrow.\n GI: + bs\ns . good appetite.\n CV: restarted on coreg at noon, and her lasix which is ordered for\n 16pm.\n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356495, "text": "Impaired Skin Integrity\n Assessment:\n pt. was seen by vascular and the plan was for vat placement this am,\n but machine not available. pt. has 2 heel ulcers. Both drsgs changed\n this am. Also noted to have several small open areas on , which\n was assessed by the skin nurse yesterday, but are now open and\n draining. Noted to have a black pinpoint area on left finger from\n fingersticks.\n Action:\n Allevyn drsg to . Heels stage 2 and calf stage 4.\n pt. does c/o discomfort at the site of the stage 2 on .\n Turned.\n Response:\n When off site, pain is relieved.\n Plan:\n Plan for vat placement tomorrow. By vascular. Need to assess this\n finger.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Creat 2.8 this am. Cont. on renal diet. c/o being itchy. Pt. c/o being\n thirsty.\n Bs\ns covered with ssi. K+ 4.6. foley in place-small amts of urine.\n Action:\n + bruit (right fistula). Iv kvo d/c\n Response:\n Hemodynamically stable.\n Plan:\n Hemo tomorrow. Cont. on renagel.\n Problem - Description In Comments\n Assessment:\n Pt. was transfused on for a hct of 25.2. post tx and or hcts have\n remained at 30. urine is blood-tinged. Foley in place. No further\n vaginal bleeding noted.\n Action:\n No c/o pain. Temp 98.9-99.1 today. Wbc\ns improved. No c/o abd pain.\n Response:\n Bleeding resolved.\n Plan:\n Continue foley. observe for clots and increased bleeding.\n Pmh: niddm, hx of pvd, hx of atrial fib. Hypercholesteremia. ESRD on\n hemodialysis. Hx of bladder ca. hx of depression. Hx of anemia and\n constipation. s/p smoker for 10yrs. Quit 8 yrs ago. NKA .\n PRESENT ILLNESS: pt. came to the ed from , where she\nd been a\n patient for 1 week for vacular issues. Pt. had developed vaginal\n bleeding and was hypotensive on adm. To the ed. . Pt. was seen by\n urology and underwent a cystoscopy with partial removal of tumor which\n was found to be invading the bladder wall. Sections sent for pathology.\n Pt. transf from the or for further management.\n NEURO: alert and orientated. Wants to go back to . They\n been notified by the case management and they are coming in to screen\n her again. Nervous about not getting out before the storm tomorrow.\n GI: + bs\ns . good appetite.\n CV : restarted on coreg at noon, and her lasix which is ordered for\n 16pm. Pt. in at fib rate in 80\ns. hypotension resolved with fluids and\n blood.\n Access: double picc placed when admitted, as unable to place triple\n lumens. In the ed.\n Pulm: bs\ns clear. Sats 100% on ra. Dry coug productive.\n Social: son into visit.\n" }, { "category": "Nursing", "chartdate": "2105-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356510, "text": "bjbj\ns 80\nr r (\n XW D\n4$^>\nLJVBB&\n Impaired Skin IntegrityAssessment:pt. was seen by\n vascular and the plan was for vat placement this am, but machine not\n available. pt. has 2 heel ulcers. Both drsgs changed this am. Also\n noted to have several small open areas on , which was assessed by\n the skin nurse yesterday, but are now open and draining. Noted to have\n a black pinpoint area on left finger from fingersticks. Action:Allevyn\n drsg to . Heels stage 2 and calf stage 4. pt. does c/o\n discomfort at the site of the stage 2 on . Turned. Response:When\n off site, pain is relieved. Plan:Plan for vat placement tomorrow. By\n vascular. Need to assess this finger. Renal failure, Chronic (Chronic\n renal failure, CRF, Chronic kidney disease)Assessment:Creat 2.8 this\n am. Cont. on renal diet. c/o being itchy. Pt. c/o being thirsty. Bs\n covered with ssi. K+ 4.6. foley in place-small amts of urine. Action:+\n bruit (right fistula). Iv kvo d/c\ned. Response:Hemodynamically\n stable.Plan:Hemo tomorrow. Cont. on renagel. Problem - \n Description In CommentsAssessment:Pt. was transfused on for a hct\n of 25.2. post tx and or hcts have remained at 30. urine is\n blood-tinged. Foley in place. No further vaginal bleeding noted.\n Action:No c/o pain. Temp 98.9-99.1 today. Wbc\ns improved. No c/o abd\n pain. Response:Bleeding resolved. Plan:Continue foley. observe for\n clots and increased bleeding. Pmh: niddm, hx of pvd, hx of atrial fib.\n Hypercholesteremia. ESRD on hemodialysis. Hx of bladder ca. hx of\n depression. Hx of anemia and constipation. s/p smoker for 10yrs. Quit 8\n yrs ago. NKA . MRSA/VRE. PRESENT ILLNESS: pt. came to the ed from\n , where she\nd been a patient for 1 week for vacular issues. Pt.\n had developed vaginal bleeding and was hypotensive on adm. To the ed. .\n Pt. was seen by urology and underwent a cystoscopy with partial removal\n of tumor which was found to be invading the bladder wall. Sections sent\n for pathology. Pt. transf from the or for further management. NEURO:\n alert and orientated. Wants to go back to . They\n;ve been\n notified by the case management and they are coming in to screen her\n again. Nervous about not getting out before the storm tomorrow. Pt. w\n as screened-no bed til tomorrow. Pt. is aware. GI: + bs\ns . good\n appetite. CV : restarted on coreg at noon, and her lasix which is\n ordered for 16pm. Pt. in at fib rate in 80\ns. hypotension resolved with\n fluids and blood. Access: double picc placed when admitted, as unable\n to place triple lumens. In the ed. Pulm: bs\ns clear. Sats 100% on ra.\n Dry coug productive. Social: son into visit. , \n NURSING TRANSFER NOTE 12/18/ , DOB: F79\n Hospital admission date: Hospital day: 3 ICU day: 3 EMR 0051\n A Page PAGE 1 of NUMPAGES 1 &\n 2 3 = _ ` f\n\"#RS_ Q R \\\n p q w\n tuvxy{|~\n JOJQJU^JaJhf\nCJOJPJQJ^JnHtH\"h\nCJOJPJQJ^JnHtHh\nCJOJQ\n J^JaJh\nCJ_HaJh\nCJOJQJ^JaJ6&\nQkdO$$Ifed8f4k\nX(Xp#\n la\nit8f4k>kd$$Ifed8f4k\nit8f4k$Ifed8f4ku\n = _ ` f\nQkd$$Ifed8f4k\nX(Xp#\n la\nit8f4k$IfQkd\n$$Ifed8f4k\nX(Xp#\nit8f4k\n ^\n$$Ifed8f4k\n la\nit8f4k$Ifed8f4kQkd~$$Ifed8f4k\nX(Xp#\n la\nit8f4k\n$$Ifed8f4k\nX(Xp#\n la\nit8f4k$IfQkd2$$Ifed8f4k\nX(Xp#\n la\nit8f4k\n\"#$R\ned8f4kQkda$$Ifed8f4k\nX(Xp#\n la\nit8f4k$IfQkd\n$$Ifed8f4k\nX(Xp#\nit8f4kRS_ Q\nQkd$$Ifed8f4k\nX(Xp#\n la\nit8f4k$If>kd\n$$Ifed8f4k\nit8f4kQ R \\ p q w\n$$Ifed8f4k\nX(Xp#\n la\nit8f4k$IfQkdz$$Ifed8f4k\nX(Xp#\nit8f4k\n 0\n\\uwxz{}~\ned8f4kQkdD$$Ifed8f4k\nX(Xp#\n la\nit8f4k\n/Scn\n$$Ifa$l\n$If^\n$Ifl\nmnops\nCJOJPJQJ^\n HtHh\nCJaJmHnHujhf\nCJUaJhf\nCJaJhf\nCJ_HaJhf\nOJQJ^Jhf\nCJOJQJ^JaJ#h\n f\nCJOJQJZ\n^JaJ\n hf\nCJOJQJ^JaJhf\nCJOJQJ^JaJnopqrs\no_L$$Ifa$l\n$Ifl\n $Ifl\n$$If\n t\n la\ned8f4kakd\n$$If\nX( @t\n t\nh/R :p\nM$$Ifed8f4k\n!vh5\n(it8f4kc$$Ifed8f\n 4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$I\n fed8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kM$$Ifed8f4k\n!vh5\n l\n(it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$Ifed8\n f4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:\n V\np#it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kM$$\n Ifed8f4k\n!vh5\n(it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:V\n 6\np#it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$Ifed\n 8f4k\n!vh5\nl##vX#vl#:V\np#it8f4kc$$Ifed8f4k\n!vh5\nl##vX#vl#\n :V\np#it8f4kY\n 3\nPNG IHDR3\n*=sRGB\n pHYs\n5IDATx^\n \"1\n\\Cs\"\n)Ooo\nl&OY\n d\n2T_GW\n x\n+X*n0\nOl\\{\n 2\nEutttt\n`ldf$?\nhYW3\n. =z\n 2\n9/C$N2\nh%#}\nqld6\n=9! 8\n=2cg\n?-TrO\n t\ns s s s s s s`\n [T(\n ag\nQG%,K\ns s s s s s`\n{rH,0\n r\n \\\nX\\Pg\nI,=a\n `\n8Stx\ns s s s s s`m\n5w T5\n g\n ?\nWdl8\n/ZuO\n>3/t\ng@1\\e\\\ns s s s s s`r`\n oxCn(\nSvttttlq,\ns s s s s`,\n > _\n\\w04hl\n Lf;Wnr\n |\nX?Ff\nb W]\"l6r\n d_\npWoWE\n/]Iy\n9 FfqP\n X\nR.,0\n Qh\n '\nm!-aJ\nga~I:\n\"bfm\n h\nF9 A\n d\n4MC&\n ?y)\n r h\n oVKs/s`\nCXpq\nT~2~\nfw6#4\n w\n}O|32\ndfHM\nQ2~/n\"Iu\n-pl#\nH7N/\ns`[p`*2\n n\n/:qT\nTEH<3\n-,S:3\n 3\nq69M\n>+}XX\ny&c96\neW}8\n:dFk/\n;Z0U\nryBX\n9$@]c\nn623(\ng6r\"\n>K`OF=[VL\n 54\n _\ncebQ\n}xoQ\nlwc\n==Bg5\n 3;7F\n{Y@f$\nT(LB\nR54\nsh--F+\n%wlA\n ?s\n V\nnt#x\nu[\"Rc8*2s\n)w$P,\nlf:`T\nOG4r>\n N\n +\n O\n +,ejOs\no~3MNPj\n j!d\n 34\n^\n!=\nE,CUp\n9kbo\n e\nTXf0\n:i\\\\\nAcXCY\n , m\nCCb(*}\n p@0\nq=F1\nr\"2S\n<8#L\nx$1C\neBx6\n ;\n1<2,%5\nsMiXu\n yt\nIAP9\n>pj~2[r@1\n \\\n s\n&W =O\n # !bR\n 4q\n.+C6\n )\n MQ\n9Wc9D\[email protected]\nUi`N\n\"u&?\nwDEu!\n IteNk\n h\n dzZ'\n4;5K\n4f?6\n1,4c\nJ#r>2\nG]#4A\nLg2S\n 3\nT]0=\n/c+>\n R*\nQ\\a7/*|x\np8hF,)`h1\n'?)(\nw(A&n\n =\nZex8?\n#xQ9\n`VdX\n'(Yr*\nNp>t+\n\"Q7R\n ?\n(g_Z\nh+\n '\n',ba\n yCU\nn1ALB\n 8\nQN1j\n rf\n,N*s\nODf.EE\n A\nfj&4p\nW,+\\\n>N>l\n b\n2:k9\n7>:]\n q.\n^LzE\nc[2101A{\n o\npi*X\n %\nMDfL\n%<>,\n D\n0XY>\nLi1X\n4K92\n}~d&\n8mVz\n $\nfuG[\ne!EX\n*nu3Fy\n [\npr(\nh3o(\n 2\nO47+|\nh`rs\n]tp#$x\na^![6XP\n\"E(.c0Y\n5\"j9\nu8@\n\\K\n.!ii5b|\n d`\nk(:-\n*DHuORQ\ndXfDl*\n >G4\n 9N\n si\n.S&\",\n k-J~b\n #hI\nFTTh\nf+=1\nF|L&(\nz&!x\n rV&\nS6~J\n^qJ@\\\nHL7Q\n k3\n\"B*a\nA~U3\n?l)d:e2F&\nX0@&\n HLvo\n \\\n(g=4\nh_:tO}c$>\n69@.\nh,Fs~$\n z\nKZMwc M\n 5\n!^SX\n<;@H\n YMJ\nAGsa\n& Y#\nqVU.\n<7i%\n y\nB^ /\nHkE{\nV d\"\nA &o\n+h,sf7N:\n?p$'\n b\n.vW,\n6%h!\nke@W\n_~eg+nr\\]\nJx:O!T{Pr\n6OQ5\n ,@%\n gd\nsJPa\n{-/-\n @@4\nSUu}*:\n :3,\nz^\\6\n \\\n&JI4\nkE!K\n %1b'\n \"\n{Xf3\nue>C\n!3$&\na@oU.\nQdwu\n][\n ,eB\n\\M,-\n n(JV0\n d\n| ^~\nL*0i\nh%>F\n iJ\nduLXO\n& LCj\n Z|$\nq'G-\n$u,s\nRi8l#n\nvDEGg\n qXi\n `ftD\nV02$eC\n_.ae\"\nYUiM\nnffHF;\nZfN,-\n 73\nyHWV\n $\n_aqO\nA?2\"\nNrVLiiu\n aY\nrqB;\n Z\nE)^P\n#Q(#\n ^~\n k[h~\nli$A\n1pm$\n $BK\n(UEdS\n HY\n(`DJ\n O\nTTOoe\n ;\n:D{i\nRQUJf\n .L+\nWAEJg\nhKt{5\n*f{l\nzzA*CH\n R\nx/jl&[\\\n v(\n(3Z#\n:C~0=Q/\nolwL\nQ%[(\n I\n /\n z\nb+2{\nL487pL\nd>a3\n=\"R)W\nuU y\nfpU+jXUT(6<}\nj%#r\n+|Yy\n '>C\nQQOv\n&>xVuY\nZHdk\n Y2f\n *U\neuq%t\nZTm;\nN31K\n-]Jm>2\n`aeU4\nHE5&\n y\nCpVmH\n&nxRV8c/42\nkM[\n 9\nHXjgU\n*gG4G~\n \\v\n=,Fu{oY\nJpn|zb\n\\N=NAD\nz 8E\nkhE=\n H\n4MtB\n:::v?\n >+\n!,2't\n!-k\nRIby7\n?;~:\nF-\\C\n Oih\n2% ?\nV n=\nEi ?\nr-Q)\nh\\g\n/fl&\n |\nj=8xm\n %\n+!t[\n M\n\"vIs:\nG>B@-l3\nEf3z\nJ!#+\n \n\\h\nW(onw\nVGPI\n -Z\n <#bv~p\n L\nq`2C\nFSWY\n =l>u\nr$2>\n}:3c\nd@sg8\n0tnI9x\n N\naub%v>?\nbg4R.K\n s s`+\n p\n8*0O\nELH%o+_\n;Nm;7\n eb\n,&[!f\n gt^\n x\no}k6X/\niy`f\nH9G\"\nI-w=q\n 8\nrS3m-\notS+]\n.ZE]J6\n:wVmYvu\nt!`#:'\n`F6*\n8lx\n\nk@f6\n en\nld&=9,\n A?\n m\n_?\"3\n 7\niZ#\n{s:c\n M\n )\nZ>YDf a\n \"\nE_*'\nw\\&4\nj>lZ\nYT]I\n 8\n*GPl#=R/\n UCTo\ne*~I\n f\n/ZWC\nU ~NVO.EA`\n b*\n$CEE\n$GG\nTIN1\nH'?MU]\n f\n _2\n |\nlll.e\n-c\\l\n,NZ$\n j\nH?g1\n 3\n '\nY}fl\n#|bC6\n,U7`\n Mbd3\n q\n`Laf\nFfJ,\n'uQg\nCUyY\n (9\n R\nCF&F\nVMc;@0\n &\n N+\n!;j/\nU4+'\ns|F*\n =\ny \"mU+\n(=PB\n:i;Z1\n8k-F9LX-)-'\npK 9w@\n &\n8n>*\n 6b\n T\nks1#\nY&j'A\nY$-*\nI 1+$ L\n}'1SyV\n32p}3\nnp[W\nBm1\n2au,\nZd p\n5tR4\"`\n .\ns&%ma\nGT13\n D!$A\n s r`z\n@|W8\n 0\nL1G!@!\n |~i\nx5gbY\n uT\nw\\r*\n k\n )*\n//pN@2\n[l~td\n j\nHH`v\n m\n8x :\nW\"gsP\nDS{ m&U\n |S\n h5=\n(Zg$\nR)(P1=\n )\nvThf\nC qB|\nt!'d\nG[8.\n G\nJ21,\n7+U,\ncw$f\n y\n+pFQ\nRyHc\n4) J\n f\\\n73Ccg\n1dTJ\n H\n|q{X\na.Np5|K^\n K\n)~ $\nqd&j_\n>L(V\n :S6bi\n@2fJ\n V8\n` \nBfiu3\nA ^|d\n ]4\n d\nFSP@\nw\\]Yd\n@%Vo3\n=aBD\n1lZrA\n3MV%W\np5gH\n Vd\n IbXG\n %Hg\n D\n,uYl\n \\%\nA.&'\nC8uy\nKMDv{\n )Jm\n \"iC\n *Y2\n g8\nQXBk\nZE:y\nDq)[\nhop<;\n /\nRW#g\n}F5f'X\nfsx4\n 1\n6k\\h\n gx6\n1tQ5`P\n,2xdRN{\n*Q. %\n>hl>.\n s\n ^i@\nw4x%\n Q\n;?Qr\n w\nVHY%\\\n3q#hX\n4JvA0\nL{(G\n+sft\n \"\n1M-j\nBe{+5\n ^\nC9Zg:\n P\npSN#V\n QF}\n jp@\n)NeUCK\n *\n.HEIY_V2j/D*\"\n,f4A\nW*_C\n]_q4\n8 \n@{= Y,\ns s s s s`\n.7P#\nS-S|\n^!OH\nC.c^\np`adV\n$`1%\ng&gqQ(\n q`\n9eJ8E\n$r 'P\nttttttl\n 9\nTz84\n v\nc{ 7T\n26$5^\n ;`\"\n! L)*\nSN!\nT~eO\nx7;XV\nrg0%\n @\n\\oM.\nDT>+\ni>mi\n*>Bu\n 9\nZlkb\nSvttttt\n ?\n::::::\n v\n _6\n 9\n\\+9,\nZVHk?MD\n s s s s s\n#IEND\n$$If\n!vh5\nm#vW#vm:V\n t\n$$If\n!vh5\nr#v #v?#vr:V\n t\n@NormalCJ_H aJmH sH tH DA@\nDDefault\n Paragraph FontRi@\nRTable Normal\n(No List4U`\n Hyperlink >*ph\nDFollowedHyperlink >*ph\n4`4Header\n!4 `\"4Footer\n3x Table GridA:V\n23=_`f\n ^\n\"#$RS_QR\\pqw\n \\ u no\n08f4kh\n08f4k h\n h\n08f4k h\n08f4k h\n08f4k h\n08f4k h\n0 8f4kh\n h\n08f4k h\n08f4k h\n08f4k h\n08f4k h\n h\n08f4k h\n08f4kh\n08f4k h\n08f4k h\n08f4k h\n h\n08f4k h\n h\n08f4k h\n08f4kh\n08f4kh\n08f4kh\n08f4kh\n08f4kh\n08f4kh\n08f4kh\n08f4kh\n08f4k\n O\n0hBOh\n0 BOh\n0247\n)+7!\n ?\nHEADER_TITLEHEADER_DATEPATIENT_MR_NUMBERPATIENT_NAMEPATIENT_DATE_OF\n _BIRTHPATIENT_AGEPATIENT_GENDERHOSPITAL_ADMISSION_DATE%PATIENT_DATE_OF_\n ADMISSION_TO_HOSPITALICU_DAYSFOOTER_TITLE\n Hals\n Hals\n\"Internal Data Integrity (Type 4) 1\nurn:schemas--com:office:smarttags\nplace\nurn:schemas-mic\n rosoft-com:office:smarttags\nPostalCode\nurn:schemas--com:office:smarttags\nState\nurn:\n schemas--com:office:smarttags\nCity\n ^bps}\n/4FI\n +-y\n+.eo\n?GIQ\n B G Z _\n \" & ; = D J u\n*+IKNrwx\n9 @ Z u\n:::::::::::::::::::::::::::x\n t u\n t u\n oppq\n8f4k\n23=_`f\n\"#$RS_QR\\pqw\n nos\nUnknown\nTimes New\n Roman5\nSymbol3&\nArialG\n MS -\n fg\"1\n24p p 3\n Notes.dotImpaired Skin IntegrityXPPOCXPPOC\n ?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\\]^_`abcdefghijklmnopqrstuvwxyz{|}~\nRoot Entry\nData\n1Table\nWordDocument\n80SummaryInformation(\nDocumentSummaryInformation8\nCompObj\nFMicrosoft Office Word Document\n MSWordDocWord.Document.8\n" }, { "category": "Radiology", "chartdate": "2105-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1051376, "text": " 6:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? collapsed lung, or pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with attemped L IJ. and hematuria\n REASON FOR THIS EXAMINATION:\n ? collapsed lung, or pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old female with attempted left internal jugular line and\n hematuria to assess for a cardiopulmonary process or a pneumothorax.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with radiograph of .\n\n FINDINGS: The heart is enlarged, unchanged from the prior examination. The\n lungs are clear. There is no evidence to suggest a left-sided pneumothorax.\n There is stable atherosclerosis in the thoracic aorta.\n\n CONCLUSION: Stable cardiomegaly with clear lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-11-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1051381, "text": " 6:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please eval for ? bladder mass and possible extension into n\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with known bladder mass and vaginal or ureteral bleeding. ?\n placement of bladdermass and possible errosion into other structures ? uterus\n causeing bleeding\n REASON FOR THIS EXAMINATION:\n Please eval for ? bladder mass and possible extension into nearby structures.\n PT is on dialysis and will be dialysed to remove IV dye. No PO contrast needed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FXKd MON 7:51 PM\n Extensive hemorrhage in the urinary bladder along with a known bladder cancer\n which has grown in size. Air in the bladder in the absence of a urinary \n is worrisome for invasion into the cervix or vagina. Multiple stable\n pancreatic cystic lesions, can be further assesed by non-emergent MRCP.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old female with known bladder mass and vaginal and ureteral\n bleeding; to assess for extension of the bladder mass into adjacent\n structures.\n\n TECHNIQUE: CT of the abdomen and pelvis was performed post-administration of\n intravenous contrast, reconstructions were performed in the axial, sagittal\n and coronal planes.\n\n Comparison is made with CT of .\n\n FINDINGS:\n\n CT ABDOMEN AND PELVIS POST-ADMINISTRATION OF INTRAVENOUS CONTRAST:\n\n There are several blebs noted at the lung bases. There is minimal atelectasis\n at the lung bases. There is extensive coronary atherosclerosis present.\n\n There are several indeterminate subcentimeter hypodensities in the right lobe\n of the liver. These were barely visualized on the prior examination, most\n likely due to phase of contrast. The spleen, adrenal glands, and kidneys\n appear unremarkable. There is mild perinephritic stranding.\n\n There is stable appearance to the numerous low attenuation cystic lesions\n noted in the head, body, and tail of pancreas. The largest located in the\n tail and measures approximately 20 x14 mm. There is no associated pancreatic\n ductal dilatation. There is no free fluid in the abdomen.\n\n There are multiple surgical clips in the right mid abdomen, likely from a\n prior bowel resection.\n\n There are scattered diverticula seen in the colon without evidence of\n diverticulitis.\n (Over)\n\n 6:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please eval for ? bladder mass and possible extension into n\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is a mass in the left lateral bladder wall, which demonstrates\n heterogenous architecture as well as enhancement. Layering high attenuation\n material in the dependent portionof the bladder may represent early nonmixed\n excrete IV contrast or hemorrhage from the tumor. It is technically difficult\n to exactly measure the extent of the mass due to hemorrhage within the urinary\n bladder. An approximate measure of the mass is 52 x 31 mm, previously 40 x 27\n mm. This mass appears to abut/involves the left ureterovesical junction,\n although there is no proximal hydronephrosis. There is air present within the\n bladder dome. This maybe due to recent instrumentation, otherwise a fistulous\n communication to the cervix or the upper vagina should be considered. In the\n right groin, there is an occluded right SFA graft as well as occlusion of the\n native right superficial femoral artery.\n\n MUSCULOSKELETAL:\n\n There are multilevel degenerative changes present in the spine. There is\n diffuse generalized osteopenia.\n\n CONCLUSION:\n 1. Urinary bladder tumor and likely hemorrhage. It is technically difficult\n to assess the exact extent of the tumor due to surrounding hemorrhage, though\n the mass approximately measures 52 x 31 mm, previously 40 x 26 mm.\n 2. Air within the urinary bladder, if no recent instrumention fistulous\n communication is a concern.\n 3. Multiple cystic lesions in the pancreas likely representing side branch\n IPMNs. No associated pancreatic ductal dilatation. An MRCP would be helpful\n for further characterization.\n 4. Extensive atherosclerosis in the coronary arteries as well as the\n abdominal and pelvic vasculature with an occluded right superficial femoral\n artery graft as well as occlusion of the native right superficial femoral\n artery.\n 5. Indeterminate tiny hepatic hypodensities were barely visualized on the\n prior examination due to different phase of contrast. A liver ultrasound\n would be helpful for further characterization of these or alternatively these\n can be assessed at the time of the MRCP.\n\n" }, { "category": "Radiology", "chartdate": "2105-12-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1051526, "text": " 12:59 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval of PICc\n Admitting Diagnosis: BLADDER CA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with PICC placement\n REASON FOR THIS EXAMINATION:\n eval of PICc\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: PICC line placement.\n\n FINDINGS: AP single view of the chest demonstrates now the presence of a\n left-sided PICC line seen to terminate overlying the SVC at the level 5 cm\n below the carina but still just above the expected entrance into the right\n atrium. There is no pneumothorax or any other placement-related complication\n and chest findings are unaltered since yesterday's examination of .\n\n IMPRESSION: Successful uncomplicated placement of PICC line.\n\n\n" }, { "category": "ECG", "chartdate": "2105-12-01 00:00:00.000", "description": "Report", "row_id": 215654, "text": "Baseline artifact. Probable atrial fibrillation. Borderline low voltage.\nLate R wave progression. Since the previous tracing of the rate\nis faster.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2195-07-29 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 831840, "text": " 8:10 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: R/O PNEUMONIA\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76y/o M with h/o CAD here for preop for CABG.\n\n REASON FOR THIS EXAMINATION:\n PREOP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 year-old man with CABG.\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n A comparison is made with a previous chest radiograph dated .\n\n FINDINGS: The heart is enlarged in size. The pulmonary vasculature is\n prominent. There is continued patchy opacity in the left lower lobe. The\n pacemaker is in position. There is degenerative change in the spine.\n\n IMPRESSION: 1. Cardiomegaly with prominent pulmonary vasculature, suggesting\n congestive heart failure.\n\n 2. Continued appearance of left lower lobe patchy opacities, suggesting left\n lower lobe pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2195-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832199, "text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumo\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x3; pt. to be in CSRU approx. 1PM s/p chest tube\n removal\n REASON FOR THIS EXAMINATION:\n ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 76 y/o man status post CABG. Status post chest tube\n removal. Evaluate for pneumothorax.\n\n TECHNIQUE: Single AP view of the chest is provided.\n\n FINDINGS: There is no evidence for pneumothorax. There is a moderate left\n pleural effusion associated with atelectasis of the left lower lobe.\n Underlying infiltrate cannot be excluded. The cardiac silhouette is enlarged.\n The patient is status post median sternotomy. Swan-Ganz catheter has been\n removed as well as chest tube in the left hemithorax. Right IJ introducer is\n still present with the tip at the level of the right cephalic vein. ET tube\n has been removed.\n\n IMPRESSION:\n 1) Status post removal of ET tube, Swan-Ganz catheter, and left chest tube.\n 2) New left pleural effusion and increased atelectasis of the left lower\n lobe. Underlying infiltrate cannot be entirely excluded.\n 3) No evidence for pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-28 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 831728, "text": " 9:13 AM\n CAROTID SERIES COMPLETE; VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: r/o carotid \n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with\n REASON FOR THIS EXAMINATION:\n r/o carotid \n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Preop for CABG.\n\n FINDINGS: Neither greater saphenous vein was visualized. The patient has a\n below knee amputation on the left.\n\n On the right significant calf edema is identified. However, the lesser\n saphenous vein is patent with diameters of 0.24, 0.39 and 0.3 cm from the\n ankle to the popliteal fossa respectively.\n\n\n CAROTID SERIES COMPLETE: Minimal plaque was identified on the left.\n\n On the right peak systolic velocities are 97, 81, 160 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 1.1. This is consistent with no\n stenosis.\n\n On the left peak systolic velocities are 77, 91, 87 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.8. This is consistent with a less than\n 40 percent stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Minimal plaque with a left less than 40% carotid stenosis. On the\n right there is no evidence of carotid stenosis.\n\n" }, { "category": "Radiology", "chartdate": "2195-08-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 832563, "text": " 7:37 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG w/poor permanent pacer sensing-check lead placement\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76y/o M with h/o CAD here for preop for CABG.\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/poor permanent pacer sensing-check lead placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76 year old male with coronary artery disease, referred for\n preoperative evaluation prior to CABG.\n\n TECHNIQUE: PA and lateral chest.\n\n COMPARISON: .\n\n FINDINGS: The patient has undergone median sternotomy and CABG. A single\n chamber pacing lead is noted in stable position. As before, there is\n cardiomegaly. There is no pulmonary vascular engorgement. There is continued\n left lower lobe opacity concerning for atelectasis or pneumonia. This was\n present on a prior study from . There is a tiny right pleural\n effusion.\n\n IMPRESSION: Persistent left lower lobe opacity, concerning for atelectasis or\n pneumonia. This was present on a prior study from .\n\n\n" }, { "category": "Radiology", "chartdate": "2195-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832013, "text": " 2:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x3; pt. to be in CSRU approx. 1PM\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG x 3.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST, AP UPRIGHT: The patient has undergone interval median\n sternotomy and CABG. The right IJ Swan-Ganz catheter tip is seen extending\n into the main pulmonary outflow tract. There are bilateral chest tubes. No\n pneumothorax is identified. There are two mediastinal drains as well as an NG\n tube seen coursing below the diaphragm. There is some minimal, left lower\n lobe atelectasis. The pulmonary vasculature is within normal limits. The\n single- lead right-sided pacer is in unchanged position.\n\n IMPRESSION:\n 1) No evidence of pneumothorax.\n 2) Right IJ Swan-Ganz catheter tip extending to the main pulmonary outflow\n tract. It is advised that the Swan-Ganz catheter be advanced to be more\n properly situated.\n\n" }, { "category": "Radiology", "chartdate": "2195-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832265, "text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x3; pt. to be in CSRU approx. 1PM s/p chest tube\n removal\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 76-year-old man status post CABG. Chest tube removal.\n Clinical suspicion for pneumonia.\n\n Single AP of chest is provided.\n\n FINDINGS: There is marked cardiomegaly. There is mild increased density in\n the left retrocardiac region with associated pleural effusion. This may\n represent atelectasis versus infiltrate. Compared to prior film from , there has been improved aeration of the left lower lobe. There is no\n evidence for pneumothorax. Right IJ introducer is noted with the distal tip\n at the level of the brachiocephalic vein. A pacemaker is also noted with a\n single lead in the right ventricle. Patient is status post median sternotomy\n and CABG.\n\n IMPRESSION: Atelectasis versus infiltrate in the left lower lobe with\n associated effusion. These findings have decreased with improved aeration in\n the left lower lobe compared to prior film from .\n\n" }, { "category": "Radiology", "chartdate": "2195-08-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 833143, "text": " 11:56 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x3; pt. to be in CSRU approx. 1PM s/p chest tube\n removal\n REASON FOR THIS EXAMINATION:\n r/o inf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG. S/P chest tube removal.\n\n COMPARISON: \n\n UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The patient is S/P median\n sternotomy and CABG. The heart remains stabily enlarged. A right-sided single\n chamber pacemaker is again seen with single lead overlying the right\n ventricle, in unchanged position. There has been improved aeration of the\n left lung base with only patchy residual atelectasis seen. A tiny right\n pleural effusion is seen, decreased in size since the prior study. Pulmonary\n vascularity is within normal limits. No pneumothorax is present.\n\n IMPRESSION:\n 1) Improved aeration within the left lung base with residual patchy\n atelectasis.\n\n 2) Tiny right pleural effusion.\n\n 3) No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2195-07-29 00:00:00.000", "description": "CT CHEST W&W/O C", "row_id": 831902, "text": " 3:54 PM\n CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please evaluate for pneumonia vs. non-infectious lesion.\n Admitting Diagnosis: R/O PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with persistent LLL infiltrate x 10 days, but with no clinical\n signs of pneumonia and awaiting surgery.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia vs. non-infectious lesion.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left lower lobe infiltrate.\n\n TECHNIQUE: Contiguous 5 mm axial images of the chest were obtained without\n the administration of IV contrast. There is no previous CT study to compare.\n\n FINDINGS: Bilateral small pleural effusions with pleural thickening and small\n atelectasis are noted. There are bibasilar patchy atelectasis. Otherwise,\n there is no consolidation noted. The main trunk of the pulmonary artery\n measures 37 mm in diameter, which may represent pulmonary artery hypertension.\n In the contrast enhanced study, there is a delay of contrast enhancement, with\n extensive ________ in the left subcutaneous regions. The narrowing of the\n middle left subclavian vein is noted where it enters the left thorax.\n\n Small mediastinal lymph nodes are noted, some of which are calcified.\n\n The patient has coronary artery calcification.\n\n IMPRESSION: 1) Bilateral small pleural effusion with pleural thickening and\n atelectasis. There is no consolidation in the lung fields.\n\n 2) The main trunk of the pulmonary artery is enlarged in size. This may\n represent the patient pulmonary hypertension.\n\n 3) There is a delay of contrast enhancement, with extensive ________. The\n narrowing of the medial portion of the left subclavian artery is suspected.\n\n" }, { "category": "ECG", "chartdate": "2195-07-29 00:00:00.000", "description": "Report", "row_id": 186485, "text": "Atrial fibrillation and ventricular paced rhythm. Occasional intrinsic\nA-V conduction. Otherwise, no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2195-07-28 00:00:00.000", "description": "Report", "row_id": 186486, "text": "Atrial fibrillation and ventricular paced rhythm. Compared to the previous\ntracing of ventricular fusions are no longer recorded. There is no\ndiagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2195-07-30 00:00:00.000", "description": "Report", "row_id": 186483, "text": "Ventricular paced rhythm\nAtrial mechanism uncertain\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2195-07-29 00:00:00.000", "description": "Report", "row_id": 186484, "text": "Ventricular paced rhythm\nAtrial mechanism is probably atrial fibrillation\nSince previous tracing of same date, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2195-08-02 00:00:00.000", "description": "Report", "row_id": 1396366, "text": "RN progress note\nneuro: AAO x 3; no focal deficits. Med w/ percocet q 4-5 hrs.\n\nCV: NSR, no ectopy, 60-80's. Pulses by Doppler.\n\nPulm: congested cough productive large amounts thick yellow sputum. BS course throughout w/ crackles bibasilar, some clearing after diuresis.\nSpO2 92-94 on 5L/NP during sleep, 94-96 WA. Poor IS effort.\n\nGI: abd soft, non-tender; BS wnl. Tol diet, no N/V; no BM.\n\nGU: UOP adequate, brisk diuresis w/ lasis 20 mg IV. RF WNL.\n\nMS/derm: sternum stable; skin w/o breakdown. Diffuse puritic erythemic raised rash over entire torso and extremities...?etilogy since no new meds today. Received last dose vanco 0800 today. Responded w/ decreased puritis, inflamation to benadryl 25mg IV q 6h. No associated respiratory issues.\n\nLabs: essentially stable\n\nP: aggressive bronchial hygeine. OOB today w/ switch to floor bed to allow pt control of position. F/U rash; prn benadryl\n" }, { "category": "Nursing/other", "chartdate": "2195-08-02 00:00:00.000", "description": "Report", "row_id": 1396367, "text": "CV: NSR 70's with PVCs, PPM when asleep; neo cont off and pressures 110's. Harvest site RLE with mod drainage, MD notified and seen, pressure dsg applied and RLE elevated\n\nResp: Dim with rhonchi in bases, needs bronchial hygiene/CDB, sats in 90's on 4L\n\nGI/GU: BS present all 4 quad; good uo after lasix 20 mg iv\n\nSkin: Diffuse itchy rash (?vanco), some relief with Benadryl 25 mg iv\n\nEndo: BS in 120s, covered with SS\n" }, { "category": "Nursing/other", "chartdate": "2195-08-03 00:00:00.000", "description": "Report", "row_id": 1396368, "text": "Update\nO: cv status: stable bp on no gtts. sr w occ to rare pvc while awake, ppm rhythm while asleep.Distal pulses doppler to weak palp rt foot. Lt bk area . ace wrap removed as pt c/o painful, uncomfortable. area ,, no brkdwn.No further bldg from rt vein harvest site.\n\nresp status: bbs clear ^ lobes, decr lll. Dbc w/o raising sputum, o2 sats adeq on 4np.\n\nneuro status: slept well overnight med x 1 for incisional pain.aaoriented.wheelchair dependant.\n\ngi status: abd soft, bowel snds +. glucose rx per ss.\n\ngu status: huo bdline to qs w lasix.\n\nintegum: full body macular rash ? etiology.\n\nA/P: Stable. Pulm toilet & oob w assist phys therapy? some wt bearing.? Transfer to 2 today. Check am labs and rx lytes per orders.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-30 00:00:00.000", "description": "Report", "row_id": 1396360, "text": "OP DAY S/P CABG X 3 WITH FREE RIMA, LIMA, LESS SVG\nTO CSRU FROM OR V PACED WITH EPICARDIAL WIRES AT RATE OF 90. PERMANENT PACER PACING AT 60 WHEN EPICARDIAL WIRE RATE REDUCED. NO AFIB NOTED. EPINEPHRINE GT @ .01MCG/KG/MIN PER DR. . EPINEPHRINE GTT TO REMAIN ON FOR 6HRS POST-OP OR TILL 1900/HR. NITROGLYCERINE GTT ON @.3MCG/KG. NITROGLYCERINE GTT TO REMAIN ON TILL AM WHEN ISOSORBIDE STARTED. NEOSYNEPHRINE USED INTERMITTENTLY TO KEEP SBP ~ 100. DR. REQUESTS THAT PT SBP REMAIN ABOUT 100 AND THAT MEASURES BE USED TO AVOID HYPERTENTION. UNABLE TO LOCATE R DP. R PT PRESENT BY DOPPLER. R 2ND TOE SLIGHTLY DARKER IN COLOR THAN REMAINDER OF FOOT COLOR.\n\nBREATHSOUNDS CLEAR BILATERALLY. CURRENTLY WEANING ON CPAP. PLAN TO CHECK ABG SOON. MEDIASTINAL AND R AND L PLEURAL CT DRAINING SEROSANGUINOUS MATERIAL.\n\nOGT DRAINING BILIOUS. NO EVIDENCE OF BLOOD. INITIALLY ORDERED TO START ASA TONIGHT. PLAN TO START ASA EC 81MG TOMORROW DUE TO H/O PUD AND GIB. ABD SOFT. ABSENT BOWEL SOUNDS.\n\nURINE OUTPUT ADEQUATE VIA FOLEY.\n\nAWOKE AND MAE. MORPHINE SULFATE GIVEN IV ONCE FOR STERNAL AREA PAIN.\n\nORIGINAL OPERATIVE DRESSINGS ON AND INTACT.\n\nBLOODSUGAR ELEVATED. INSULIN GTT STARTED PER CSRU BLOOD GLUCOSE MANAGEMENT PROTOCOL.\n\nINR ELEVATED. FFP ORDERED. NO EVIDENCE OF BLEEDING. ORDER TO TRANSFUSE DC'D AFTER DISCUSSION WITH DR .\n\nONLY FAMILY MEMBER REPORTED TO BE HIS SISTER IN . NO CALLS OR VISITORS THIS SHIFT.\n\nPLAN TO CONTINUE VENT WEANING AND ASSESSMENT. PT'S OWN WHEELCHAIR REPORTED TO BE IN DR. OFFICE. PLAN TO FOLLOW UP TOMORROW. PT HISTORY NOTES HE DOES NOT HAVE DENTURES. NEED TO TAKE SOFT SOLIDS WHEN READY TO EAT.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2195-07-30 00:00:00.000", "description": "Report", "row_id": 1396361, "text": "Resp Care\nPt received from OR s/p CABG. Pt placed on SIMV-parameters noted.\nBreath sounds essentially clear, but decreased in bases. Currently remains on CPAP with plans to extubate soon.\n" }, { "category": "Nursing/other", "chartdate": "2195-08-01 00:00:00.000", "description": "Report", "row_id": 1396364, "text": " B:\n\nNeuro: alert and oriented x3, mae, following commands correctly, pearl, percocets for pain.\n\nCardiac: nsr in the 70's to 100%v paced with own internal pacer at 60, ocasional pvc's, sbp's wnl's is weaning down off neo this shift, dopplerable pedial pulses, skin warm dry and intact, afebrile, +2 edema in extremities.\n\nResp: lungs dim in bases, on 4 liters nc satting around 96%, abg good, is coughing and deep breathing and using i/s, no air leak inct system that is draining moderate serosang.\n\nSkin: chest with dsd that is , ct dsd , right leg with dsd that is , pt reports that right knee is frozen, and that he is wheelchair bound at baseline, left leg bka from 02.\n\nGi/GU: tolerating po's abd soft round and nontender, hypoactive bowel sounds, on riss, making good u/o with lasix.\n\nPLan: wean off neo, ? d/c pacing wires today, increase activity, encourage to cough and deep breath and to use i/s.\n" }, { "category": "Nursing/other", "chartdate": "2195-08-01 00:00:00.000", "description": "Report", "row_id": 1396365, "text": "CSRU NPN\n\n\nNeuro: Oriented x 3. Appropriate in conversation. Moving extremities at baseline activity.\n\nCV: NSR with rate 60-70's with occ v pacing from PPM. Occ PAC's noted. HR down to high 50's NSB with sleep. Epicardial wires removed without incident. BP stable off neo. SBP occ drifts to high 90's briefly. Tolerated 12.5 mg lopressor. Coumadin cont's. Lytes repleted. CT's removed.\n\nResp: BS clear but diminished in lower lobes. O2 sats occ drift to 92% but most of time > 93%. Needs much encouragement to cough/deep breathe and use IS. IS up to ~750cc. Cough weak much of time but occ productive dk yellow secretions.\n\nGI: Abd soft. + BS. Tolerating solids.\n\nGU: Adequate response to morning lasix. u/o drifting down this afternoon.\n\nEndo: SSRI per protocol.\n\nSkin: Intact. Incisions clean, dry. Scant serousang dng from leg incision.\n\nActivity/Comfort: c/o chest incision and CT site pain most of time. Percocet q 4 hrs. Uses darvocet at home for chronic back pain. oob to chair. Tol chair x 3 hrs. PT to work w/ pt tomorrow on bed to W/C transfer.\n\nA: Stable hemodynamically.\n\nP: Cardiac meds per orders. Pulmonary hygiene. Pain med prn. OOB to chair as tolerated. Diuresis.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-31 00:00:00.000", "description": "Report", "row_id": 1396362, "text": " B:\n\nNeuro: alert and oriented x 3,mae,following commands correctly, pearl, c/o of back pain with movement throughout shift and has mso4 for pain, pt reports that he takes darvocets at home for back pain.\n\nCardiac: v paced at 90 with external pacer for bp, pt does have own internal pacer set at v demand, cardiology to see pt today to interigate pacer, occ pvc's, sbp's wnl' while on neo for nitro gtt due to graft will start isosorb in am, ci's and outputs all wnl's, dopplerable pedial pulses, skin warm dry and intact, +2 edema in extremities, afebrile.\n\nResp: when asleep pt mouth breath and ra sats dip to 93% on 100% face mask, while awake with coughing and deep breathing ra sats are 97%, abgs good when awake borderline good while asleep, no leak in ct system which is draining moderate sero sang.\n\nSkin: chest with dsd that is , ct dsd's , right leg ace which is , pt reports that right knee is frozen and needs to be elevated on pillow.\n\nGi/Gu: tolerating ice chips, abd soft round and nontender, hypoactive bowel sounds, continues riss gtt, u/o did at one time drop below 30 to 25 and md a one time of 20 iv lasix given with good results.\n\nPlan: increase activity as tolerates, monitor for pain and tx, monitor u/o, start isosorb this am and shut off nitro gtt post and wean neo as tolerates, pt reports that he uses wheelchair at baseline and that it is at md office.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-31 00:00:00.000", "description": "Report", "row_id": 1396363, "text": "S/P CABG\nD/A: Nitro off after PO imdur this am. Cont with Neo for low SBP/MAP, see flow. Hypotensive when OOB to chair with , neo titrated. Decreased epicardial pacer to backup rate of 56 @ 1700, toll well at this time. EP here earlier this afternoon, no changes, awaiting return to adjust perm pacer. Occas. PVC's noted. Electrolytes , sx aware. Lungs clear with decreased bases. Sats 95-96% on 5L via NC. Uses incentive spirometer q1 500-750cc. Good productive cough with thick tan secretions. Abd soft and nondistended with hypoactive bs. Adv diet as toll. A&Ox3. MAE to command. Very difficult for pt to move RLE secondary to PMH. Unable to get oob with assist, needs to chair. All drains and dressings intact, see flow. Foley with adequate clear yellow urine, lasix started this am. C/O severe lower back pain and generalized stiffness, percocet prn. blood sugar via sliding scale.\nR: Cont to attempt to wean neo. Encourage pulm toilet and po diet. Will attempt oob later this pm. Keep pain controlled. Awaiting EP reuturn before d/c epicardial wires. Will cont to \n" } ]

[ { "category": "Radiology", "chartdate": "2166-06-22 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1025653, "text": " 8:43 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: identify vascular lesion\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p carotid stent placement with subsequent intracranial\n hemorrhage\n REASON FOR THIS EXAMINATION:\n identify vascular lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg MON 7:40 PM\n Stable appearance of subarachnoid hemorrhage without evidence of aneurysm or\n underlying vascular malformation. Recommend conventional catheter angiogram\n for further evaluation if clinically indicated. MRI and MRA of the brain,\n unchanged GI .\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN\n\n INDICATION: 68-year-old female status post carotid stent placement with\n subsequent intracranial hemorrhage. Identified vascular lesion.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the\n brain. No contrast was administered. Three-dimensional time-of-flight MR\n arteriography was performed.\n\n COMPARISON: CTA HEAD W/ AND W/0 CONTRAST ON .\n\n FINDINGS:\n MRI BRAIN: Abnormal signal is noted in the perimesencephalic cistern, basal\n cistern, and the left cerebral convexity throughout. These areas correspond\n to increased intensity on diffusion-weighted imaging and areas previously\n noted on CTA of the head. There is no aneurysm or vascular malformation\n visualized to indicated the origin of the subarachnoid blood. There is no\n evidence of mass, mass effect, or large vascular territory infarction.\n\n MRA OF THE HEAD. Plaque is noted bilaterally in the right carotid and left\n carotid arteries without evidence of stenosis or occlusion. There is an\n apparent area of stenosis in the right MCA bifurcation that was not\n demonstrated on prior CTA and may be due to motion artifact. The intracranial\n vertebral arteries, their major branches and the major branches of the left\n ICA appear normal without evidence of stenosis, occlusion, or aneurysm\n formation.\n\n IMPRESSION:\n 1. Stable subarachnoid hemorrhage without clear cause. Recommend\n conventional catheter angiogram for further evaluation.\n 2. Possible stenosis of the right MCA bifurcation. CT with sedation is\n recommended if clinically indicated.\n 3. Intracranial atheromatous disease as described above.\n\n (Over)\n\n 8:43 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: identify vascular lesion\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Findings were discussed with Dr. at 12 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2166-06-22 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1025654, "text": ", M. NSURG SICU-B 8:43 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: identify vascular lesion\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p carotid stent placement with subsequent intracranial\n hemorrhage\n REASON FOR THIS EXAMINATION:\n identify vascular lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Stable appearance of subarachnoid hemorrhage without evidence of aneurysm or\n underlying vascular malformation. Recommend conventional catheter angiogram\n for further evaluation if clinically indicated. MRI and MRA of the brain,\n unchanged GI .\n\n" }, { "category": "Radiology", "chartdate": "2166-06-24 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 1025964, "text": " 9:39 AM\n CAROT/CEREB Clip # \n Reason: please evaluate for aneurysm, AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n * CERVICOCEREBRAL A-GRAM EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n please evaluate for aneurysm, AVM\n ______________________________________________________________________________\n FINAL REPORT\n DIAGNOSIS: Subarachnoid hemorrhage.\n\n INDICATION: Rule out source of hemorrhage. is a 68-year-old\n female with a heavy history of smoking who underwent left carotid\n endarterectomy in . She subsequently had ischemic symptoms in\n her left hemisphere and was found to have a tightly stenosed common and\n internal carotid artery. This was stented at Hospital. Two\n days postoperatively she developed hemorrhage in the left frontal lobe and\n significant subarachnoid hemorrhage in the prepontine cistern. Therefore she\n was referred to us for ruling out a definite source of hemorrhage as this was\n felt not to be related to the stenting procedure.\n\n Requested by Dr. .\n\n ANESTHESIA: Moderate sedation was provided by administering 50 mcg of\n Fentanyl and 1 mg of Versed for the 35 minute intraservice time during which\n the patient's hemodynamic parameters were continuously monitored.\n\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, left common\n carotid artery arteriogram, left vertebral artery arteriogram, aortic\n bifurcation arteriogram, aortic arch runoff.\n\n ATTENDING:\n The patient was brought to the angiography suite. IV sedation was given.\n Following this, the right groin area was prepped and draped in a sterile\n fashion. We now gained access to the right common femoral artery using\n Seldinger technique. Following this, wire was passed into the\n distal aorta, and a 23 cm 5 mm long sheath was placed into the distal aorta.\n An arteriogram was done which revealed stents in both iliac arteries, however,\n they were widely patent. Now using a 5 French pigtail catheter an aortic arch\n runoff was done to specifically look at the origin of the left common carotid\n artery where a stent had been previously placed. There was no stenosis at the\n (Over)\n\n 9:39 AM\n CAROT/CEREB Clip # \n Reason: please evaluate for aneurysm, AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n origin. We therefore now cannulated the right common carotid artery, the left\n common carotid artery and the left vertebral artery and AP, lateral filming\n was done. Because of the tortuosity of the left vertebral artery, the\n catheter was nosed into the origin of the left vertebral artery rather than\n going higher up and injections done from the proximal vertebral artery. This\n did not reveal any aneurysms or any critical stenosis. No AV dural fistula\n was identified. Though the patient was moving considerably during the\n procedure, reasonable images were obtained and I did not feel an examination\n under general anesthesia was indicated.\n\n FINDINGS: Aortic bifurcation arteriogram demonstrates diseased bifurcation\n with no critical stenosis. Both common iliacs fill well. Multiple stents\n seen in both common iliac arteries bilaterally with no evidence of critical\n stenosis.\n\n Aortic arch runoff demonstrates that the origin of the left common carotid\n artery where a stent has been previously placed is widely patent. The left\n subclavian artery origin is also patent. The right innominate takeoff was not\n well visualized on this injection.\n\n Right common carotid artery arteriogram demonstrates normal filling of the\n right external carotid artery and its branches. There is no critical stenosis\n at the bifurcation though there is significant ulcerated plaque at the\n bifurcation. The right internal carotid artery fills well along the cervical,\n petrous, cavernous and supraclinoid portion. No aneurysms seen either in the\n anterior cerebral artery or the middle cerebral artery territory. There is no\n cross fill into the left hemisphere.\n\n Left vertebral artery arteriogram shows significant kinking of the vertebral\n arteries proximally with what appears to be extreme tortuosity of the\n vertebral artery and mild stenosis in the mid segment of the vertebral artery\n segment at the C5 level. There is reflux into the right vertebral artery.\n Both left and right PICAs are seen well. Both PCAs and superior cerebral\n arteries are seen well with no evidence of aneurysms, AV malformations or AV\n fistula. Left common carotid artery arteriogram shows that the carotid\n bifurcation is patent. There is about a 50% stenosis of the right external\n carotid artery at the origin. The stent which extends from the left common\n carotid bifurcation into the left internal carotid artery is patent. The\n intracranial runs demonstrate that the left internal carotid artery fills well\n along the cervical, petrous, cavernous and supraclinoid portion. The left A1\n is somewhat attenuated. The left middle cerebral artery is seen with no\n evidence of aneurysms.\n\n IMPRESSION: underwent cerebral arteriography which was limited\n by motion artifact, however, this failed to reveal any source of subarachnoid\n (Over)\n\n 9:39 AM\n CAROT/CEREB Clip # \n Reason: please evaluate for aneurysm, AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemorrhage. Specifically, there were no aneurysms, AVMs or AV dural fistula.\n No critical stenosis was also identified on any of the arteriograms. There is\n attenuation of the left A1 division which could be secondary to vasospasm.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1025606, "text": " 8:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with COPD, new 02 requirement, leukocytosis\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old with COPD and new oxygen requirement with\n leukocytosis. Evaluate for pneumonia.\n\n COMPARISON: .\n\n SINGLE AP UPRIGHT BEDSIDE CHEST RADIOGRAPH: This exam is quite lordotic.\n There is no focal consolidation to suggest pneumonia. The lungs are grossly\n clear. No sizable effusion or pneumothorax. The cardiomediastinal silhouette\n is likely unchanged when accounting for lordotic technique. Median sternotomy\n wires again noted.\n\n IMPRESSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-06-21 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1025597, "text": " 4:42 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with report of spontaneous ICh at OSH. Severe HA\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKSb SAT 7:47 PM\n No evidence of aneurysm. Scattered areas of SAH (?trauma history) at cranial\n vertex, left frontal lobe, and basal cisterns. No hydrocephalus.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE HEAD\n\n HISTORY: Spontaneous ICH, assess for source.\n\n Images of the unenhanced CT are limited due to motion. There appears to be\n perimesencephalic and suprasellar subarachnoid hemorrhage. Subarachnoid\n hemorrhage is also seen in the left frontal convexity scattered throughout.\n There is moderate intracranial vascular calcification. Within limits of this\n examination, no aneurysm or stenosis is seen. There is a focal calcification\n in the left intradural vertebral artery, which creates artifactual impression\n of an aneurysm in this locale on the volume-rendered images.\n\n IMPRESSION:\n\n No definite evidence for aneurysm seen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-06-24 00:00:00.000", "description": "Report", "row_id": 1641894, "text": "Neuro:Pt alert and oriented X3. Continues to C/O headache. Med with fiorocet with adequate pain relief. PEARLA, normal strength all extremities.\n\nCV: afebrile, HR 50-70's NSR with no noted ectopy. SBP remains <140 continues on nicardipine gtt at 0.5, unable to wean due to boarderline SBP. lytes WNL.\n\nRESP: lungs clear diminished at bases. Requiring 4l N/C to keep O2 sats >90%. Occasional harsh cough with scant amount of clear secretions.\n\nGI: NPO since 12am. Abd soft with +BS. No stool overnight.\n\nGU: foley draining adequate clear yellow urine.\n\nENDO: blood sugar this am WNL.\n\nPLAN: awaiting cerebral angio this am. Cont to monitor SBP to keep <140, attempt to wean nicardipine.\n" }, { "category": "Nursing/other", "chartdate": "2166-06-24 00:00:00.000", "description": "Report", "row_id": 1641895, "text": "RN progress note\nSee Carevue for specifics\n\nNeuro: Pt oriented x 3 but currently a bit lethargic likely d/t pain meds. Rouses and answers all questions appropriately, though slowly. PERRL. Continues to c/o severe HAs of . Tx'ing with fioricet with result of pain level . Pt also continue to have episodes of nauseau & vomitting. Tx'ing with zofran with positive result. Pt underwent cerebral angiogram today, initial report negative for abnormalities.\n\nCV: NSR/SB. Angio site pulse via doppler. Distal pulses easily palpated. Nicardipine gtt still on.\n\nRESP: LS clear, very productive strong cough. Sats >95% on 4L NC.\n\nGI: Cardiac diet restart tonight. No stool. Abd more distended but soft.\n\nGU: Foley putting out large amounts of light yellow urine.\n\nPLAN: Start PRN hydralizine, wean from nicardipine gtt. Continue to tx pain agressively. Transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2166-06-23 00:00:00.000", "description": "Report", "row_id": 1641892, "text": "please see carevue for alllabs, values, specifics.\n\nn: pt on q3 neuro checks. PERL at 2mm. Bilateral equal strength, slight weakness on RUE with drift noted. C/o severe h/a ~0200 and received 2 tabs vicodin with good effect. Pt consistantly with UO>200cc/h from 2200 on-- light yellow/unconcentrated urine in appearance. SICU team aware, Dr. evaluated. Concern for DI considering location of pt's ICH. Awaiting AM labs for further detail.\n\ncv: SBP goal<140, pt back on nicardipine gtt after trying PRN labetalol and PRN lopressor for hypertension to 160s. HR SB-NSR, 50s-60s. PPP. Afebrile.\n\nresp: ls clear, diminished. put back on NC at 3L d/t pt desaturating to 88- low 90s when asleep. Wet cough, not raising secretion\n\ngi: abd soft, nt. bs+. npo.\n\ngu: foley draining light yellow/clear urine amts>200cc/h from 2200 on. Lasix 20mg PO was given at .\n\nendo: on ISS. BS 104/217.\n\nplan: f/u on ?DI. Nicardipine gtt for SBP<140. Neuro q2. Pain control. ?Angio today for further investigation of bleed.\n" }, { "category": "Nursing/other", "chartdate": "2166-06-23 00:00:00.000", "description": "Report", "row_id": 1641893, "text": "RN progress note\nSee Carevue for specifics\n\nPt remains A&O x 3 but c/o of severe HA (10 on pain scale) which was only mildly relieved by Vicodan (8 on pain scale). Fioricet given with positive result, bringing pain down to 3 on pain scale. One episode of vomitting. Normal motor strength, OOB to chair with minimal assist. PERRL. NSR/SB. Home cardiac meds started. Nicardipine gtt at 0.5. SBP much resolved with relief from pain. LS clear, >95% on 4LNC, very productive cough. Remains NPO except for meds. Foley draining adequate light yellow urine. Family in to visit.\n\nPLAN: Angio tomorrow. NPO after midnight. Wean from nicardipine gtt as tolerated, titrating to keep SBP < 140. Manage pain agressively.\n" }, { "category": "Nursing/other", "chartdate": "2166-06-25 00:00:00.000", "description": "Report", "row_id": 1641896, "text": "neuro- intact. no deficits noted.moves independantly.follows all commands.appropriate actions. continues to have sudden onset of sporadic sharp-pain headaches. wtith light sensitivity. medicated with 2 fiorocet with relief of symptoms.\n\ncv- afebrile. nsr-sb with no ectopy. nicardipine remained off with control of SBP < 160 with oral antHTN and iv hydralazine q6h. no edema + pp.\n\nresp- 4lnc =95-100%. ls with exp wheezez and scattered rhonchi. neds/puffers given a/o. strong non-productive cough.\n\ngi- abs soft. taking p.o. meds without difficulty. no nausea.\n\ngu- auto diuresing large amts clear urine.\n\nendo- covered wth RISS and fixed dose insulsin.\n\nplna: continue to monitor neuros/glucose levels. transfer to floor. today.\n\n" }, { "category": "Nursing/other", "chartdate": "2166-06-22 00:00:00.000", "description": "Report", "row_id": 1641889, "text": "Admission note \nPt is s/p L internal carotid stenting procedure at , developed R sided weakness and severe h/a. Head CT revealed hemorrhage, trans . CT/CTA done showing (-) hydrocephalus/aneurysm. Pt did have blood glucoses in 300-400 range in ED. Brought to SICU for monitoring of neuro status/BP/BS.\n\nN: Pt a/o x3. Has hx of parkinson's disease (past 7 yrs.) and therefore has difficulty writing/holding hands/arms out without shaking. Able to lift all extremities off bed to command. Noted to have RUE drift. Slightly unequal in bilateral strength with weakness noted in RUE. Transient h/a, pt denied pain when asked. PERLA at 2mm. No narcotic/pain med administered in ED for h/a.\n\nCV: HR SB-NSR. SBP goal <140, on nicardipine gtt to maintain at .75mcg/kg/min. PPP. Pt with known hx of CAD/PVD. Afebrile.\n\nRESP: Hx of COPD- asthma/emphysema. LS diminished through out. On NC 2L, o2 sats 92-100. Wet cough, not raising secretion. On RTC nebs given by RT.\n\nGI: Abd soft, nt. BS+. NPO for procedure.\n\nGU: Foley inserted on arrival to SICU for immediate 110cc. HUO ~ 35cc. Pt started on cipro for UTI.\n\nENDO: On insulin gtt, BS range 180-311.\n\nSOCIAL:\r Pt's daughter called for update. Contact #s received.\nPLAN: MRI for -- forms completed and faxed. Cont Nicardipine to maintain SBP goal<140. Cont Insulin gtt for BS control. Neuro q 2hr. Pt/ family support.\n" }, { "category": "Nursing/other", "chartdate": "2166-06-22 00:00:00.000", "description": "Report", "row_id": 1641890, "text": "***NSG ADDENDUM:\n\n~0400AM, pt HR inc to ST ~100, pt shivering/rigors, states \"im so cold, my head is throbbing.\" temp taken, 97.8 orally. bear hugger applied. Neuro exam unremarkable/unchanged. NSURG/SICU teams both aware. Dr. per phone call believed this is d/t parkinson's. pt then confirmed this often happens to her. IVP dilaudid given for severe onset of h/a.\n" }, { "category": "Nursing/other", "chartdate": "2166-06-22 00:00:00.000", "description": "Report", "row_id": 1641891, "text": "condition update\nplease see carevue for specifics.\n\nPt is alert and oriented x 3. Able to MAE. PERRL. Neuro exam monitored Q2 hours. Pt went for an MRI this am. Results pending. Tmax 99.4 SR-SB. No ectopy noted. HR 56-88. Nicardipine gtt off since 0800am. SBP goal < 140 and maintained w/ po meds. Pt c/o HA. Pt received 2 vicodin tabs w/ + effect. LS CTA. Nebs and inhalers given. Pt w/ a non productive cough. 02 sats 95-100% RA. Pt remains NPO till results of MRI back. NS infusing at 80cc/ hr. Foley patent and draining 25-100cc/ hr. BS 92-236 and covered w/ riss. Integ intact. Family in to visit and updated by nmed consult.\n\nPlan: continue w/ current plan of care per sicu/ nsurg teams. continue to closely monitor neuro status Q 2 hours. Follow up on results of MRI. Maintain SBP <140. Vicodin for HA.\n" }, { "category": "ECG", "chartdate": "2166-06-21 00:00:00.000", "description": "Report", "row_id": 141292, "text": "Sinus rhythm. Slight non-specific inferior ST segment elevation with\nnon-diagnostic Q waves. Clinical correlation is suggested. Compared to the\nprevious tracing of probably no significant change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2123-06-25 00:00:00.000", "description": "Report", "row_id": 62543, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nHeight: (in) 72\nWeight (lb): 260\nBSA (m2): 2.38 m2\nBP (mm Hg): 160/60\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 15:33\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement. No thrombus/mass in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. No LV mass/thrombus. Overall normal LVEF (>55%). No resting\nLVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. No thrombus/mass is seen in the body of the\nleft atrium. No atrial septal defect is seen by 2D or color Doppler. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Regional left ventricular wall motion is normal. No masses or\nthrombi are seen in the left ventricle. Overall left ventricular systolic\nfunction is normal (LVEF>55%). There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No masses or vegetations are seen on the\naortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. No mass or\nvegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is\nseen. The pulmonary artery systolic pressure could not be determined. There is\nan anterior space which most likely represents a fat pad.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1026626, "text": " 9:43 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please assess for tumor, amyloid, ischemia, and other prior\n Admitting Diagnosis: STROKE;TELEMETRY\n Contrast: MAGNEVIST Amt: 23\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with with left frontal hemorhrage.\n REASON FOR THIS EXAMINATION:\n Please assess for tumor, amyloid, ischemia, and other prior hemorrhages.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 1:22 PM\n A left temporal hematoma is identified. No underlying enhancing brain lesion\n seen.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with left frontal hemorrhage.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following gadolinium. Correlation was made with the previous\n CT of .\n\n FINDINGS: There is a large hyperacute hematoma identified in the left\n posterior temporal lobe extending to the anterior occipital lobe. The\n hematoma measures approximately 5 cm in size. There is mass effect on the\n left posterior of the left lateral ventricle. A small amount of blood is\n also seen in the occipital of the left lateral ventricle. There is\n surrounding edema identified. There is no midline shift. Following\n gadolinium, no distinct enhancement is seen within the hematoma or in the\n surrounding brain or in other parts of the brain. There is no abnormal\n meningeal enhancement seen.\n\n Again noted is a prominent CSF space in the left anterior temporal region\n consistent with an arachnoid cyst as seen on the previous CT. Also noted are\n soft tissue changes within the sella and within the clivus indicative of\n pituitary adenoma with probable previous surgery. These findings are\n unchanged from the previous CT of . If further evaluation of the sella\n lesion is clinically indicated, a dedicated MRI of the sella can help.\n However, there is no compression of the optic chiasm seen.\n\n There are a few small foci of low signal on GRE images indicating chronic\n microhemorrhages.\n\n IMPRESSION: Left posterior hematoma without signs of underlying enhancement\n or abnormal vascular structures. Presence of chronic microhemorrhages may\n suggest amyloid angiopathy but follow up is recommended.\n\n Sellar abnormality as described above.\n\n (Over)\n\n 9:43 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please assess for tumor, amyloid, ischemia, and other prior\n Admitting Diagnosis: STROKE;TELEMETRY\n Contrast: MAGNEVIST Amt: 23\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2123-06-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1026627, "text": ", H. NMED TSICU 9:43 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please assess for tumor, amyloid, ischemia, and other prior\n Admitting Diagnosis: STROKE;TELEMETRY\n Contrast: MAGNEVIST Amt: 23\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with with left frontal hemorhrage.\n REASON FOR THIS EXAMINATION:\n Please assess for tumor, amyloid, ischemia, and other prior hemorrhages.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n A left temporal hematoma is identified. No underlying enhancing brain lesion\n seen.\n\n" }, { "category": "Radiology", "chartdate": "2123-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1026994, "text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with afib, ICH\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: 75-year-old male with AFib and intracranial hemorrhage, evaluate for\n pneumonia.\n\n FINDINGS: Exam is extremely limited due to patient uncooperation. There are\n low lung volumes. The mediastinal silhouette appears widened and is likely\n due to technique. The patient's chin obscures the upper lung fields. There\n appears to be an increased retrocardiac opacity, which may be due to technique\n versus atelectasis or early infection. A small left pleural effusion is also\n identified and unchanged. There has been interval removal of the ET tube and\n NG tube since prior exam. There is no evidence of pneumothorax.\n\n IMPRESSION: Extremely limited exam with possible retrocardiac opacity which\n may be due to technique. Repeat study is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2123-06-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1026780, "text": " 4:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: HEAD BLEED\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with head bleed\n REASON FOR THIS EXAMINATION:\n changes in bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SAT 8:41 AM\n No change in size, degree of surrounding edema, or mass effect of the large\n left posterior temporal hemorrhage, with tiny intraventricular extension,\n unchanged from the prior MR, but new from prior CT of .\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT.\n\n COMPARISON: Head CT dated , and MRI dated , 10:35\n a.m.\n\n FINDINGS: There is no significant change in the size of the large left\n posterior temporal hematoma or mass effect in the left posterior of the\n left lateral ventricle. Small amount of blood is seen in the occipital \n of the left lateral ventricle, new from the prior CT of , but\n persistent from , MR. There is no shift of normally midline\n structures or hydrocephalus. There are no new foci of hemorrhage. Area of\n surrounding vasogenic edema is stable.\n\n The sella abnormality described on the recent CT and the MR is stable in\n appearance, and as previously stated may represent a pituitary adenoma, which\n might have undergone surgery.\n\n Arachnoid cyst in the left anterior temporal region is stable.\n\n IMPRESSION:\n 1. No significant change in the large left posterior temporal hemorrhage or\n debris of the mass effect. No new foci of hemorrhage.\n\n 2. Stable appearance of the sella abnormality compared to .\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1026781, "text": ", H. NMED TSICU 4:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: HEAD BLEED\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with head bleed\n REASON FOR THIS EXAMINATION:\n changes in bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No change in size, degree of surrounding edema, or mass effect of the large\n left posterior temporal hemorrhage, with tiny intraventricular extension,\n unchanged from the prior MR, but new from prior CT of .\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1026623, "text": " 9:36 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OGT placement\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with head bleed, intuabted and sedated\n REASON FOR THIS EXAMINATION:\n OGT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 12:49 PM\n Since earlier today, ETT tip is 4.5 cm above the carina. Nasogastric tube is\n in the stomach. Moderate left pleural effusion with retrocardiac opacities\n increased suggesting aspiration, blood, or less likely atelectasis. Vascular\n congestion decreased.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 75-year-old man with head bleed, intubated and sedated.\n Nasogastric tube placement.\n\n Since earlier today, ETT tip is 4.5 cm above the carina. Nasogastric tube is\n in the stomach.\n\n Moderate left pleural effusion with associated retrocardiac alveolar opacity\n increased suggesting aspiration or atelectasis. Vascular congestion\n decreased. No other change since earlier today.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1026624, "text": ", H. NMED TSICU 9:36 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OGT placement\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with head bleed, intuabted and sedated\n REASON FOR THIS EXAMINATION:\n OGT placement\n ______________________________________________________________________________\n PFI REPORT\n Since earlier today, ETT tip is 4.5 cm above the carina. Nasogastric tube is\n in the stomach. Moderate left pleural effusion with retrocardiac opacities\n increased suggesting aspiration, blood, or less likely atelectasis. Vascular\n congestion decreased.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1026531, "text": " 9:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhage, stroke\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with R sided weakness\n REASON FOR THIS EXAMINATION:\n eval for hemorrhage, stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:30 PM\n 4.9 x 4.4 cm parenchymal hemorrhage in the left temporal lobe with mild\n surrounding edema and mass effect on the left occipital .\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: Acute stroke.\n\n FINDINGS: There is a 4.9 x 4.4 cm left temporal parenchymal hemorrhage with\n a thin rim of surrounding vasogenic edema, with mild mass effect on the\n occipital of the left lateral ventricle. There are no other foci of\n hemorrhage and no intraventricular extension. There are mild periventricular\n white matter hypodensities, consistent with microangiopathic changes. There\n is no shift of normally midline structures or hydrocephalus.\n\n On the review of bone windows, there is bony remodeling and expansion of the\n sella turcica and soft tissue attenuation internally, which may be seen in the\n setting of an exopansile pituitary mass.\n\n Imaged paranasal sinuses are well aerated.\n\n IMPRESSION:\n\n 1. Left temporal parenchymal hemorrhage.\n\n 2. Findings concerning for a pituitary mass. Further evaluation with MR is\n recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1026533, "text": " 9:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with stroke\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable AP view of the chest.\n\n INDICATION: 75-year-old male presenting with stroke.\n\n COMPARISONS: None.\n\n FINDINGS: The lung volumes are low. The heart may be mildly enlarged. An\n ill-defined area of opacity is noted at the left lung base and obscures the\n left hemidiaphragm. Otherwise, the lungs are grossly clear. The aorta is\n mildly tortuous and aortic calcifications are evident. There are mild\n degenerative changes of the left shoulder.\n\n IMPRESSION: Left lower lobe airspace process which may represent infiltrate,\n atelectasis or aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2123-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1026550, "text": " 12:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation.\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with left hemispheric stroke.\n REASON FOR THIS EXAMINATION:\n s/p intubation.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:52 A.M. ON \n\n HISTORY: Left hemispheric stroke.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are appreciably lower, moderate cardiomegaly is unchanged, but\n mediastinal and pulmonary vascular congestion accompanied by mild pulmonary\n edema indicate cardiac decompensation. Consolidation at the lung bases,\n particularly the left could be combination of dependent edema and atelectasis,\n but pneumonia particularly aspiration must be considered. ET tube in standard\n placement. No pneumothorax or appreciable pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1027138, "text": " 3:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval for placement of NGT\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with NGT placement\n REASON FOR THIS EXAMINATION:\n Eval for placement of NGT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 6:24 PM\n Since earlier today, the Dobbhoff tube was installed with its tip in distal\n right lower lobe bronchus. Left retrocardiac alveolar opacity is unchanged.\n Results were communicated immediately with the patient's nurse at the time of\n .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n COMMENTS: 75-year-old man with nasogastric tube placement. Evaluate for\n placement.\n\n Since earlier today at 6:24, a Dobbhoff tube was installed with its tip in\n distal right lower lobe bronchus.\n\n Left retrocardiac alveolar opacity is unchanged. Left lateral\n costodiaphragmatic angle was excluded. Findings were discussed immediately\n over the phone with the patient's nurse at the time of .\n\n" }, { "category": "Radiology", "chartdate": "2123-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1027139, "text": ", H. NMED FA11 3:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval for placement of NGT\n Admitting Diagnosis: STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with NGT placement\n REASON FOR THIS EXAMINATION:\n Eval for placement of NGT\n ______________________________________________________________________________\n PFI REPORT\n Since earlier today, the Dobbhoff tube was installed with its tip in distal\n right lower lobe bronchus. Left retrocardiac alveolar opacity is unchanged.\n Results were communicated immediately with the patient's nurse at the time of\n .\n\n" }, { "category": "Nursing/other", "chartdate": "2123-06-27 00:00:00.000", "description": "Report", "row_id": 1661703, "text": "Nursing Progress Note\nSee Carevue for Specific Data.\n\nSignificant Events: Q2 hr neuro checks continue, neuro status unchanged overnight. Nicardipine gtt weaned off, BP WNL.\n\nNeuro: Pt slept comfortably for most of the night, intermittently alert, spontaneously opening eyes. Inconsistently following commands: squeezes and releases hand, occasionally wiggles toes, does not hold up thumb. Pupils 3mm/3mm and briskly reactive. Pt assists with turning and occasionally attempts to turn on own. Pt heard swearing but makes rare verbal communication otherwise. Pt , left side > right side. Unable to determine orientation. Pt makes eye contact with speaker when standing on pt's left side.\n\nPain: Pt appears to be comfortable at rest and during repositioning.\n\nCV: HR 70-80's, NSR, rare PVCs. Nicardipine gtt weaned off, BP WNL. Per HO goal BP is 160's (no range given)- systolic BP 150's throughout shift. Easily palpable pedal pulses, PBoots for DVT prophylaxis.\n\nResp: Lung sounds coarse in upper lobes, diminished at the bases bilaterally. Pt started shift with 2L nc and humidified face (40%/10L). Pt continued to remove face , nc increased to 3L and used alone, sats >94%. ABG with low PaO2 so face re-applied, nc discontinued, pt leaving oxygen therapy on while sleeping, sats >96%. Repeat ABG to be drawn. Pt has productive cough, able to swallow/spit secretions (tan, thick)\n\nGI: Abdomen soft, obese, hypoactive BS, last BM unknown. Pt NPO at this time d/t OG tube removed at extubation, no colace given overnight. IV fluid: NS @ 75cc/hr while NPO.\n\nGU: Adequate clear, yellow, UO through foley qhour.\n\nEndo: BS covered by RISS-BS 150-160's. RISS tightened in AM.\n\nID: Afebrile, no antibiotics, WBC WNL 9.\n\nSkin: Back intact, repositioned frequently. Right hand/wrist/5th digit with red rash and bruising-possibly from arterial line placement?\n\nSocial: No calls overnight.\n\nPlan: Continue q2 hr neuro checks v. change to q3-q4 hrs? Monitor BP per goal. ?Speech/Swallow eval in the AM Hoff/NG tube to provide nutrition. ?Transfer to SDU/floor d/t no ICU need at this time. Continue to support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2123-06-25 00:00:00.000", "description": "Report", "row_id": 1661699, "text": "T/SICU Nursing Progress Note\n0700-1900\n\nSee Carevue for exact data.\n\nSignificant Events:\n(1) Pt to MRI for scan of head. (2)EKG done at bedside. (3) Echocardiogram done at bedside. (4) Chest xray to eval placement of OG tube. (5) Fluid challenge of 500cc LR for low urine output/rising creatinine\n\nReview of Systems:\n Pt sedated on Propofol 50mcg/kg/hr. Responds to verbal stimuli, inconsistently follows commands, pupils 3mm/3mm briskly reactive. MAE's L>R. Corneals, cough, gag intact. Neuro checks q 1 hour.\n\nCV- SR with occasional PVC's, HR 60-80's. BP 120-160's/50-70's. Nicardipine 1-3mcg/kg/hr used briefly throughout shift, goal of SBP 120-160. Cardiac enzymes negative. Hct 45. Inr 1.5. EKG and Echo done at bedside. Compression boots for prophylaxis, no anticoagulation at this time.\n\n Pt with #8 ETT, 22@teeth. On CMV TV 600, 40%, Peep 5, Rate 12. ABG Ph 7.43/PaCO2 36/PAO2 139, CO2 25. LS clear with diminished bases bilaterally. Trialed on PSV, unsuccessful. Thick white secretions suctioned orally. Scant thick/white secretions with deep suction. Oral care per VAP protocol.\n\nGI/GU- Abd soft, obese, bs present. OGT with TF running, Replete with fiber at goal of 45. No residuals. Foley with clear, light yellow urine. Fluid challenge of 500cc LR in am, pt responded well, output >100/hour now. Bun 36, Creat 1.2\n\nEndo- RISS, SS tightened for hyperglycemia. Pt regularly requiring insulin coverage. Hx DMII.\n\n Wife, son and nephew in to visit today. Spoke with neuro team at length re: poc, disease process. Cont to provide emotional support.\n\nPlan- ? wean vent to cpap with pressure support, ? plan to extubate tomorrow, neuro checks q 1 hour, titrate nicardipine for goal of SBP 120-160. Cont Tf at goal.\n" }, { "category": "Nursing/other", "chartdate": "2123-06-25 00:00:00.000", "description": "Report", "row_id": 1661696, "text": "admit note.\n\n75yr man driving home from foxwoods and noticed some dysphasia. refused to go to ED. At home 6 hours later, pt slid down bathroom wall due to right side flacidity. incresed dysphagia also noted. wife called 911, pt taken to , code stroke.\nCt scan showed 4.9 X 4.4 cm parenchymal bleed in left temporal with edema mass effect on the left occipital .\nIn ED SBP up to 260. pt started on nicardipine with little effect. INR 3.3 vit K and prophaline given. pt neuro status declined in pt became aphasic, left side defcit noted as well as right. nystagmus noted. pt became more somulent.\nupon arrival to T/SICU a-line placed, gag absent, neuro exam poor. remained aphasic. ABG 7.17/84/183/32. pt intubated.\n\nneuro- pt sedated on propofol, due to coughing and disych with vent. will localize to trapezius pinch, but did not withdraw from nailbed pressure. has spontaneous movement in all 4 ext, but not to command or nailbed pressure. PERL 2mm brisk. + corneals.\n\nCV- HX afib. in and out of fib on admit. currently in SR 60-80. cont on nicardipin goal to keep b/p >100 <140. lopressor PRN.\n\nResp- intubated 8.0 ETT, lung sounds very diminished. o2 weaned to keep sat >92. hx COPD. vent AC TV 700 40% rate 14 peep 5.\n\nGI- aBD soft, obease. + BS. OGT to sx. NPO.\n\nGU- foley. clear u/o. u/a sent from ED. urine tox sent from ICU.\n\nendo- s/s coverage bs 252, hx dm type 2.\n\nskin- no issues.\n\nsocial- wife and son in to see pt. update given questions answered.\n\nplan- to MRI today, check list sent. ? repeate CT this am. EKG and Echo today. ? start pt on dilantin.\n" }, { "category": "Nursing/other", "chartdate": "2123-06-25 00:00:00.000", "description": "Report", "row_id": 1661697, "text": "Respiratory Care\n75 yo male developed garbled speech at 2 pm referred to pt refused to go. 8 pm wife found pt down. Pt recieved CT in the ED found to have a large head bleed. Pt transfered to TSICU and then intubated due to the pt mental status. Intubated with a 8.0 ETT 22 at the teeth. Suctioned for thick white secretions. BS rhonchi and diminished at the bases. RSBI of 88. Plan: Continue mechanical ventilation until further notice.\n" }, { "category": "Nursing/other", "chartdate": "2123-06-25 00:00:00.000", "description": "Report", "row_id": 1661698, "text": "Respiratory Care\nPatient remains on ventilatory support with all settings and changes documented in Carevue. Decrease in rate to 12 bpm from 18 bpm. Plan is to extubate in the morning.\n" }, { "category": "Nursing/other", "chartdate": "2123-06-26 00:00:00.000", "description": "Report", "row_id": 1661700, "text": "Respiratory Care:\nPt remains intubated and vented. Parameters changed to PSV 5/5 .30. Tolerating well. Suctioned for mod amts white secretions. Morning RSBI = 44.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-06-26 00:00:00.000", "description": "Report", "row_id": 1661701, "text": "T/SICU Nursing 19-07\nNeuro: Sedated on propofol now at 15mcg/kg/min. Lightened as possible but begins to gag/cough/sit up. GCS=4/1.0/5. Pupils 3-4mm, equal, round, briskly reactive to light. Gag, cough, corneal reflexes intact. Does not follow commands or interact with examiner. Seems to have right sided neglect. Moves all extremities L>R. Head CT done at 6am.\n\nPain: No nonverbal signs of pain.\n\nResp: Lungs clear, equal bilaterally. Ventilated on CPAP+PSV 5 with 5PEEP 30%. Intermittent periods of apnea seem unrelated to level of sedation. PCO2 51 ok per Dr . Suctioned for scant thick white sputum.\n\nCV: Sinus rhythm with occasional vea. Nicardipine off, goal SBP<160 maintained with prn lopressor and hydralazine. Ext warm and well perfused with 3+ pulses. P-boots in place.\n\nGI: Abd obese. Bowel sounds hypoactive. Tube feeds at goal 45 per ogt with no residuals. No BM.\n\nGU: Foley to gravity drains clear yellow urine qs.\n\nEndo: RISS with coverage as ordered; this patient may benefit from an insulin gtt, which has not been ordered by the team.\n\nLytes: WNL.\n\nSkin: Intact.\n\nID: Tmax 100.2, no abx. WBC 9.4. VAP care per protocol.\n\nSocial: No family contact.\n\nPlan: Maintain safety; pain & sedation management; q2 neuro checks; ween to extubate; maintain SBP<160 MAP<130; cont tube feeds and bowel regimen; monitor fluid & electrolyte balance; tighten fsbg control; follow for signs of infection; possibly extubate this am; notify team of acute changes; d/c-dispo planning; emotional&social support.\n" }, { "category": "Nursing/other", "chartdate": "2123-06-26 00:00:00.000", "description": "Report", "row_id": 1661702, "text": "NPN 0700-1900\n\nEvents- Extubated this am without incident.\n\n Pt occ opens eyes spontaneous, consistently opens to loud voice. MAEs with varying strength, RLE moves on bed only. Not FCs for staff but did squeeze nephew's hand twice to command and smiled at them. Does not attempt any communication with RN but did attempt few incomprehensible responces to family members.\n\nResp- Extubate to 50% FT at 10am. Lungs clear to coarse BULs and diminished bases. Sats > 95%, though intially had short periods of apnea with brief drop in sats to 88%. Change to2l NC when awake but is a mouth breather while sleeping and changed back to FT.\n\nCV- Afebrile. HTN 170-190s with little effect from lopressor po and IV and IV hydralazine. Restarted Nicardipine gtt after HO clarified with neuromed for goal SBP<160. SR in 60-80s with occ PVCs. At around 1430 pt rhythm changed to afib in 110-120s. Given 10mg lopressor with little effect, repeated dose 45 minutes later, delay response but then pt converted back to NSR in 80s. Lytes drawn, awaiting results. BG remain elevated and insulin sliding scale tightened.\nSkin intact. Some bruising on R anterior little finger.\n\nGI/GU- Abd obese with + BS. OGT pulled with ETT and Pos not appropriate at this time. Discussed dobhoff with , discuss in rounds tomorrow. Foley patent with adeq UO.\n\nSocial- Family in today including wife. Updated by RN and HO. All questions answered.\n\nPlan- Maintain safety. Monitor I&Os closely. Cont freq neuro checks.\n" }, { "category": "ECG", "chartdate": "2123-06-29 00:00:00.000", "description": "Report", "row_id": 120378, "text": "Sinus rhythm. Prominent limb lead QRS voltage suggests left ventricular\nhypertrophy. Probable prior inferolateral myocardial infarction. Non-specific\nST-T wave changes. Clinical correlation is suggested. Since the previous\ntracing of atrial fibrillation is absent, lateral precordial lead\nQRS voltage is lower and further T wave changes are suggested.\n\n" }, { "category": "ECG", "chartdate": "2123-06-28 00:00:00.000", "description": "Report", "row_id": 120379, "text": "Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing of atrial\nfibrillation is new. However, the deep T wave inversions in the lateral leads\nhave partially normalized. Clinical correlation and repeat tracing are\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2123-06-25 00:00:00.000", "description": "Report", "row_id": 120380, "text": "Sinus rhythm. Widespread T wave inversions. Since the previous tracing\nof the T wave abnormalities are more prominent. Ventricular premature\nbeat is no longer seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2123-06-24 00:00:00.000", "description": "Report", "row_id": 120381, "text": "Sinus rhythm with a single ventricular premature beat. Minor ST-T wave\nabnormalities. Since the previous tracing of the T waves have\nimproved. Otherwise, as previously described.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2141-11-16 00:00:00.000", "description": "Report", "row_id": 106003, "text": "Sinus rhythm. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-11-16 00:00:00.000", "description": "Report", "row_id": 106004, "text": "Sinus rhythm. occasional ventricular premature contractions. T wave inversions\nin leads V3-V6 consistent with possible anterior ischemia. Compared to the\nprevious tracing of T wave inversion in lead V3 is new. Otherwise, no\ndiagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2141-11-09 00:00:00.000", "description": "Report", "row_id": 106005, "text": "Sinus rhythm\nProbable old Anteroseptal myocardial infarction\n Anterolateral T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "Radiology", "chartdate": "2141-11-10 00:00:00.000", "description": "ART DUP EXT LO UNI;F/U", "row_id": 746542, "text": " 1:14 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: 78 yo s/p cardiac cath complicated by retrograde disse\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with (see above)\n REASON FOR THIS EXAMINATION:\n 78 yo s/p cardiac cath complicated by retrograde dissection of right\n external iliac artery. Please evaluate flow in right common femoral\n ______________________________________________________________________________\n FINAL REPORT\n REASON: Patient status post cardiac catheterization complicated by dissection\n of the external iliac artery question lower extremity ischemia.\n\n FINDINGS: Duplex evaluation was performed of the right lower extremity\n arterial system with concentration in the inguinal region. There is triphasic\n flow in the right common femoral artery and proximal superficial femoral\n arteries. Just distal to the bifurcation there appears to either be\n significant plaque or potentially intimal flap in the superficial femoral\n artery with an area of stenosis.\n\n IMPRESSION: Based on ultrasound criteria there does not appear to be\n significant inflow disease related to the question of an external iliac artery\n dissection. However there appears to be either plaque or intimal flap in the\n proximal superficial femoral artery. Clinical correlation is warranted and an\n arteriogram may be needed.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 746820, "text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: preop. stat CXR needed because pt going to or now.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n preop. stat CXR needed because pt going to or now.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST RADIOGRAPH .\n\n INDICATION: Pre-op for vascular surgery.\n\n The heart is not enlarged. The mediastinal and hilar contours appear normal.\n There is no pulmonary vascular redistribution. The lungs are clear and there\n are no pleural effusions.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-17 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 747016, "text": " 2:38 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: s/p thrombectomy of R AT. now w/ swollen R calf with tendern\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD, new MI, s/p stent to Ramus Intermedius\n REASON FOR THIS EXAMINATION:\n s/p thrombectomy of R AT. now w/ swollen R calf with tenderness. please r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swollen right calf status post thrombectomy of right anterior\n tibial artery, rule out thrombus.\n\n Unilateral lower extremity Doppler: Grayscale and Doppler son of the\n right common femoral, superficial femoral and popliteal veins were performed.\n Normal flow, augmentation and compressibility, and wave forms are\n demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-11-14 00:00:00.000", "description": "ART DUP EXT LO UNI;F/U", "row_id": 746805, "text": " 11:17 AM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: R/O HEMATOMA/PSEUDOANEURSYM\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Cardiac cath with new right hematoma and bruits.\n\n FINDINGS: Duplex and color doppler demonstrate no pseudoaneurysm or hematoma\n involving the right inguinal area. normal appearing common femoral artery and\n common femoral veins are appreciated.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-11-14 00:00:00.000", "description": "Report", "row_id": 1406698, "text": "CCU Nursing Admit Note:\n\nMr is a 79 y/o with h/o CAD who presented to OSH with R side arm pain and CP. Pt found to have +troponin and episodes of SVT in ER. Pt was treated and transfered to for caridac cath on .\n\nPt was found to have a AMI and LAD PTCA and recent NQWMI (peak CK 533 on ). Cath revealed severe ramus stenosis, stent placed. Mild to moderate disease in the LAD, LCX, and RCA. EF 30%. The cath was complicated by dissection of the right external iliac artery causing diminished R DP/PT pulses. Pt was monitored on cardiac floor.\n\nPt underwent R lower extremitiy angiography, rec'd TPA which was delivered into the popiteal artery x 4 hrs via L fem sheath. Pt was transfered to Vascular ICU for monitoring . Pt was brought back to the cath lab were occlusion was still present attempts were made at angiojet and PTCA w/o effect. Vascular Surgey to consult in am. R groin hematoma developed after TPA in cath lab requiring fem stop.\n\nPMH: CAD. HTN. dyslipidemia. MI 5 yrs ago. Macular degeneration R eye. CVA.\nAllergies: NKDA.\n\nReview of Systems:\n\nNeuro: Pt arrived to unit alert and oriented. Pt anxious regarding pressure occulsion at groin site along with finding his dentures. Moving all extremities spontaneously. Pt became increasingly upset regarding fem stop therefore interventional fellow decreased pressure from 90 to 50 and pt rec'd serax 10mg po for c/o insomnia. Within 15 min of pressure decreased pt began to excelerate regarding pain and inability to sleep. H.O. in to assess pt rec'd morphine 2mg IV for pain and ativan .5mg iv for anxiety with resuls.\n\nCV: NSR to 2 degree AVB HR 70-80's. Pt denies CP. SBP 128-139. NTG weaned to off. All pulses dopperable.\nL fem arterial sheath with small hematoma marked in cath lab no further enlargement outside of demarkation.\nR fem site with fem stop in place. Large hematoma marked in cath lab, no further enlargement.\nHCT 33.0 repeat due at 3am. Pt to receive 2u PRBC's first unit infusing. Post cath IVF on hold during transfusion. Pt rec'd 240cc of contrast in cath lab.\n\nPULM: LS clear. Pt denies SOB. Sats 95-98% on 2l NC.\nNo peripheral edema noted.\n\nGI: Abd soft NT +BS. No stool this shift. Pt NPO for possible surgery today, await vascular consult (Dr. . Pt with brief period of nausea s/p administration of morphine resolving w/o intervention.\n\nGU: Condom cath in place initially draining yellow clear urine currently brown.\n\nSKIN: intact\n\nLINES: L fem arterial sheath. L lower arm PIV.\n\nSOCIAL: No phone calls this shift.\n\nDISPO: Full Code\n\nPROPH: TPA and hep prior to transfer.\n\nA: complications of cath R iliac artery disection with thrombus to popiteal artery.\n VSS.\nP: Await lab results. Transfuse 2u PRBC's. Assess pain at hematoma site. Check pulses. ACT at 8am for removal of L fem sheath. NPO. Monitor urine output. Provide support.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-14 00:00:00.000", "description": "Report", "row_id": 1406699, "text": "Addendum to Nursing Note:\n\nPt appeared to be sleeping well from 3-6am, no further compliant of R groin discomfort. Pt rec'd 1u PRBC's with HCT 34.8 please re check HCT prior to transfusing second unit. CPNCP.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-14 00:00:00.000", "description": "Report", "row_id": 1406700, "text": "CCU NUrsing Progress Note\nS-\"My leg aches alittle\"\nO-Neuro alert and oriented x3 but having periods of unclear confusion ie adamently dening having an ultrasound this morning despite having one. Talking at length about WW2 and crying about events.\nCV-VSS BP 95-118 with HR 70-80 had a period of tachycardia 108-112 after sheath removal but decreased after receiving lopressor 50mg po to 65. Left fem art sheath removed by card fellow 8:30am applied 20 minutes of manual pressure and then a bandaide. Small hematoma 2cm/2cm at site. Right groin femo stop appliance removed this am with moderate hematoma decreased to 3cm/3cm but eccymosis tracking down hip/leg. Pedal pulses easily doperable bilateral. Feet warm with right foot slighty cooler. Fem ultrasound completed r/o'd for pseudo anysurysm Pre op for embolectomy by anesthesia completed at 2:30pm c/o aching received tylenol 650mg po x1 this am.\nResp-Ls clear O2 sats 97% on RA\nID afebrile\nGU-condom catheter in place and voiding ~50cc/hr\nGI-NPO after MN HCT 34 after 1 u nit PRBC recheck at 1pm pnd.\nSkin-eccymosis right antecub from old IV site s/p TPA.\n Pt spoke to wife this afternoon about having surgery today.\nA/P-Stable, improved pedal pulses today. To VICU post op\n" } ]

[ { "category": "ECG", "chartdate": "2177-06-13 00:00:00.000", "description": "Report", "row_id": 256081, "text": "Sinus tachycardia. Since the previous tracing of the rate has\nincreased.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2196-11-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 991391, "text": " 9:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: POSSIBLE SEIZURE, EVAL.\n Admitting Diagnosis: ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with possible seizure\n REASON FOR THIS EXAMINATION:\n please eval for intracranial path\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with possible seizure.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT SCAN:\n\n FINDINGS: There is prominence of the ventricles, as well as the sulci\n reflecting cerebral atrophy. There is no hemorrhage, mass effect, shift of\n the normally midline structures, or major vascular territorial infarct. There\n is mild mucosal thickening of the anterior ethmoid air cells.\n\n IMPRESSION:\n\n 1. No hemorrhage or mass effect.\n\n 2. Prominent ventricles and cerebral sulci, likely related to parenchymal\n volume loss; NPH is another possibility given the greater dilation of the\n ventricles.\n\n MR head would be useful in further evaluating cause of seizures and\n ventricles.\n\n Findings will be informed to Dr. by the dept. critical result\n communicator.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2196-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991895, "text": " 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for any infiltrates consistent with pneumonia\n Admitting Diagnosis: ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with signs of withdrawal status post orthopedic surgery, low\n grade temperature\n REASON FOR THIS EXAMINATION:\n Please assess for any infiltrates consistent with pneumonia\n ______________________________________________________________________________\n WET READ: 10:31 PM\n no pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n INDICATION: Assessment for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: Radiographically, there are no major changes. Slight elevation of\n the right hemidiaphragm. No evidence of pleural effusion. Mildly enlarged\n heart with no signs of cardiac insufficiency. In the interval, no newly\n occurred opacities suspicious for pneumonia. No pleural effusions.\n\n IMPRESSION: No relevant interval changes. No pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-11-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 991390, "text": " 9:57 PM\n CHEST (PA & LAT) Clip # \n Reason: ? PNA\n Admitting Diagnosis: ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with aspiration\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP AND LATERAL CHEST ON \n\n HISTORY: Aspiration, question pneumonia.\n\n IMPRESSION: AP and lateral chest compared to 8:27 p.m. on :\n\n Aside from a mild atelectasis in the right lower lung accounting for elevation\n of the lung base, the lungs are clear on the frontal view. On the lateral\n view detail is obscured by motion, probably respiratory. There is no pleural\n effusion. Heart is mildly enlarged but there is no vascular congestion in the\n lungs or in the mediastinum compared to mediastinal venous engorgement that\n was present two hours earlier. The lateral view suggests substantial\n compression of at least one lower thoracic vertebral body with kyphosis.\n Clinical correlation advised.\n\n" }, { "category": "Radiology", "chartdate": "2196-11-06 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 991244, "text": " 10:38 PM\n ANKLE (AP, MORTISE & LAT) RIGHT; KNEE (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with right ankle open fracture\n REASON FOR THIS EXAMINATION:\n eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old male with right ankle open fracture.\n\n COMPARISON: None.\n\n THREE VIEWS, RIGHT KNEE: There is no fracture or abnormal alignment. There\n is no knee joint effusion. The overlying soft tissues are unremarkable.\n\n THREE VIEWS, RIGHT ANKLE: An overlying cast limits fine detail evaluation.\n There is an oblique fracture through the distal right fibula with one-quarter\n shaft width lateral displacement of the distal fracture fragment. Transverse\n fracture is identified through the medial malleolus. There is widening of the\n medial compartment of the mortise.\n\n IMPRESSION: Oblique right distal fibular fracture and transverse right medial\n malleolar fracture with disruption of the ankle mortise.\n\n" }, { "category": "Radiology", "chartdate": "2196-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991376, "text": " 8:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for aspiration, cardiopulm process\n Admitting Diagnosis: ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p right ankle ORIF, now w/seizure activity\n REASON FOR THIS EXAMINATION:\n please eval for aspiration, cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post right ankle ORIF, now with seizure activity, evaluate\n for possible aspiration or cardiopulmonary processes.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position demonstrates normal heart size. No typical\n configurational abnormality. Thoracic aorta unremarkable. No mediastinal\n abnormalities. The pulmonary vasculature is normal. No signs of pneumothorax\n or pleural effusion. No acute infiltrates.\n\n There exists no prior chest examination or records available for comparison.\n\n IMPRESSION: Normal findings on portable single view chest examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-11-16 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 992646, "text": " 6:25 PM\n ANKLE (AP, MORTISE & LAT) RIGHT; KNEE (2 VIEWS) RIGHT Clip # \n Reason: check hardware and fx\n Admitting Diagnosis: ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with s/p orif\n REASON FOR THIS EXAMINATION:\n check hardware and fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man status post open reduction internal fixation of\n an ankle fracture, check hardware and fracture line.\n\n COMPARISON: , and .\n\n RIGHT KNEE, TWO VIEWS: No acute fractures or alignment abnormalities are\n noted. The joint space is preserved. No evidence of degenerative changes.\n\n RIGHT ANKLE, THREE VIEWS: Right distal fibular and medial malleolar fracture\n with persistent visibility of the fracture line and no interval changes in\n alignment is noted. Surgical skin staples and lateral buttress plate with\n cortical screws in the distal fibula and medial malleolar lag screws are seen\n without evidence of hardware- related complications or loosening. Unchanged\n appearance of residual medial angulation of the distal fibular fracture\n fragment. Mild soft tissue swelling at the ankle joint. No acute fractures.\n The ankle mortise is congruent and the talar dome is intact.\n\n IMPRESSION: Oblique right distal fibular fracture and transverse right medial\n malleolar fracture, s/p ORIF, without interval changes in alignment or\n hardware- related complications.\n\n" }, { "category": "Radiology", "chartdate": "2196-11-07 00:00:00.000", "description": "R ANKLE (AP, LAT & OBLIQUE) RIGHT", "row_id": 991258, "text": " 5:48 AM\n ANKLE (AP, LAT & OBLIQUE) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \n Reason: ORIF RT ANKLE\n Admitting Diagnosis: ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Right ankle three views, .\n\n HISTORY: ORIF right ankle.\n\n FINDINGS: Comparison is made to prior study of .\n\n Six fluoroscopic images from the operating room shows placement of a lateral\n fibular fracture plate and interfragmentary screw and two lag screws through\n the right medial malleolus. The fracture lines are faintly visualized. There\n is good anatomic alignment. There are no signs for hardware related\n complications. Please refer to the operative note for additional details.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-11-08 00:00:00.000", "description": "Report", "row_id": 1625431, "text": "NPN TSICU 0700-1900\nReview of systems:\n\nNeuro: Pt with active DT's. Alert at times and only oriented to self. PT follows commands, moves all extremities purposefully and has equal and reactive pupils. Speech is slurred and tremors are present when arms are extended. Pt is sweaty at times, but has no complaints of headache, N/V. No auditiory or visual hallusinations noted. CIWA scale every hour. Ativan PRN\n\nCV: SR-ST 90-130's with no ectopy noted. HTN SBP 150-170's. PRN Hydralizine given with good effect. 3 peripheral IV's, P. boots for profolaxsis. D51/2 with 20meq KCL at 75. Kcl and K phos repleated.\n\nResp: LS clear, NC with 4L O2, Sao2 95-98%. RR 24-55 through shift, pt dose not appear to be in any distress.\n\nGI: Clear liquid diet, tolerated sips of water with pills well. BS prestent, abd soft, no BM this shift.\n\nGU: Foley cath draining large amounts clear urine.\n\nEndo: RISS for blood sugar control.\n\nskin: RLE cast intact, CSM WNL, positive pulses. Foot elevated on multiple pillows.\n\nSocial: Father called and plans to visit tomorrow.\n\nPlan: Continue to monitor CIWA and tx DT's. Monitor lytes, VS, and Neuro signs. ? social work.\n" }, { "category": "Nursing/other", "chartdate": "2196-11-10 00:00:00.000", "description": "Report", "row_id": 1625432, "text": "Nursing Admit/progress note 1715-1900\nThis 42yo man, without prior significant medical hx, had unwitnessed fall on causing a grade II bimalleolar R ankle fracture. ETOH level in ED 400. On he went to the OR for R ankle washout and internal reduction/fixation. Post-op day 1, in CC6, pt had withdrawl related seizure with a prolonged post ictal period with resp distress. Pt responded to IV Valium and NR mask, and was sent to the T-SICU. He was later transferred to the PACU as T-sicu bed was needed. He is now transferred to the MICU service and MICU-6 to treat further withdrawl symptoms. PACU reports that pt requires sedation approx Q2hrs, and is otherwise combative and dangerous to staff. A sitter is present in room after pt was evaluated by psych nurse.\n\nReview of systems:\n\nNeuro: Pt oriented to self only. He is alternately sleeping or verbally aggressive to staff and trying to exit bed. He denies auditory and visual hallucinations, and also denies pain. His skin is damp but he is not sweating excessively. Faint tremor occas visible. He slurrs his words and speaks in short sentences only, stating he wants to go home or needs to go to work. His resp rate is irreg with occas snoring. Shortly after admit to MICU-6 he D/C'd his IV and began kicking and trying to exit bed. Security called and present until IV established so meds could be given. Pt presently in 4pt restraints with sitter @bedside.\n\nResp: Pt on 3l NC with O2 sat 100%. RR 16-25 and irreg. Lung snds clear, diminished in bases.\n\nCV: HR 99-114SR without ectopy. BP 127/75-133/79. Pt refused am dose Lopressor. All labs sent, results pndg.\n\nGI: Abd soft with + BS, passing flatus. Pt NPO except for ice chips.\n\nGU: Foley draining yellow urine in adequate amts per carevue.\n\nAccess: Pt presently with 1 periph IV: #18 in LLP arm, protected by kerlix wrap.\n\nID: Temp 99.4po on admit. WBC WNL. CXR done, results pndg.\n\nSocial: Father and brother have visited pt in hospital. Family was unaware of pt's ETOH abuse.\n\nPlan: Cont RTC sedation @ this time for withdrawl symptoms. Cont sitter and 4pt restraints @ this time for pt and staff safety. IV hydration. ?pt willing/able to take po meds.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-11-11 00:00:00.000", "description": "Report", "row_id": 1625433, "text": "MICU nursing progress note 7P-7A\nEvents - Pt slept for 5 hrs 7P->12AM, awoke very agitated, attempting to get OOB, asking for restraints to be removed. Swearing constantly at staff. Oriented to self only, place is hospital, year is consistently even after reorientation many times. Mod tremor in hands, pulling at restraints, pulling off and telemetry leads. Attempted to punch this RN, threatening to urinate \"all over all of you\". MICU team in to evaluate pt many times. CIWA , changed sedation from ativan to valium. Pt has received total of valium 70mg IVP and MSO4 6 mg at time of this note. Transient sedation is now being acheived with meds with pt dozing off for ~ 1 hr after meds given. 4 point soft restraints maintained as pt attempts to kick or hit staff. Sitter in room at all times to maintain safety to patient. Low stimulation environment.\n\nResp - Lungs clear, diminished at bases. Sats 97-100%. RR 20->32 Pt will occ hold his breath, enc to take deep slow breaths.\n\nCV - NSR 80s when asleep. HR^^ 100s-120s with agitation. NBP 130-150s/80s-100s. Unable to give PO lopressor as pt combative, agitated when awake. Labs obtained last evening WNL, LFTs^^.\n\nGI - NPO. IVF started NS 150cc/hr. And soft, distended, +BS. No stool.\n\nGU - UOP 80-200cc/hr via foley.\n\nPlan - CIWA scale, Valium and MSO4 to effect. Sitter at bedside. restraints as needed for safety to pt and staff. Psychiatry is following. Low stimulation environment.\n" }, { "category": "Nursing/other", "chartdate": "2196-11-08 00:00:00.000", "description": "Report", "row_id": 1625430, "text": "42 y old male with long hx of ETOH was admitted s/p fall and r/ankle fx, was post op day one on the CC6 where he started with DTs and last night vomited and had a witnessed seizure, code blue was called and pt was trx to TSICU.\n\nassessment as noted in carevue\n\nres: on coolmist 70%, maintains sat > 95, on ra 88-89, RR increased during the night to >40, pt denies SOB ? part of DT? ls clear/dim, see abg results in chart\n\nneuo: frequent ativan given.confused at times and delusional, resis to care and got restrained -was trying to pull lines, tremmors and sweats, slurred speech, mae exp r.leg-in cast., getting morphine for pain(r leg)\n\nlabs: k, mag, phos were repleted, on LR+40 k iv fluids\n\nsocial: no family calls, no proxy given, some belonings are in safe and some are on CC6\n\nplan: monitor DTs and res closely, intubate if abg worsening, pain control\n" }, { "category": "Nursing/other", "chartdate": "2196-11-11 00:00:00.000", "description": "Report", "row_id": 1625434, "text": "MICU Nurse Progress Note 0700-1900\nEvents: pt much more cooperative w/ care, remains anxious/ agitated at times, easily redirected. Haldol prn x1 w/ good effect per psych rec. restraints/ sitter d/c'd.\n\nNeuro: A/O x2, reoriented to year (stated that it was when asked). remains somewhat lethargic, speech is slurred. MAE, follows commands, easily redirected when anxious. psych clin spec. in to see pt, rec. changing benzos to haldol. haldol given x1 w/ good effect. CIWA scale 8-12.\n\nPulm: rec. pt on 3l n/c, 02 d/c'd, LS: CTA 02 sat 94-99% on RA.\n\nCVS: SR HR 90's-110's, no ectopy, b/p 121-153/66-106. pt able to take po b/p meds. peripheral IV x1 in L arm, IVF d/c'd.\n\nGI: taking PO's well, diet advanced to house diet. abd soft non tender w/ +BS med loose stool x1 this shift.\n\nGU: foley cath intact patent, draining clear yellow urine 60-150ml/hr.\n\nsocial: father in to see pt , updated r/t pt condition, SW consult pending r/t ETOH abuse.\n\nPlan: pt c/o to floor pending bed availability.\ncont CIWA monitoring prn.\n" }, { "category": "Nursing/other", "chartdate": "2196-11-12 00:00:00.000", "description": "Report", "row_id": 1625435, "text": "1900-0000 transfer note\nPt. sitting upright eating meals, food all over bed, some upper ext tremors noted. some agitation, cooperative with turns and assessment\n\nNEURO: able to state name, place and date correctly , sluggishly. CIWA scale noted. Haldol 5 mgm given at bedtime.\nCV: stable\n\nRESP: diminished at bases bil. cough non prod. room air sats 96%. cooperative with CDB\n\nGU/GI: foley amber, qs, BT no stool, takes diet very well. po tol. with SBA\n\nACCESS: 1 piv in right arm with good blood return\n\nPAIN: denies\n\nORTHO: ace wraps and hard cast on. pp intact, cms wnl. elevated on pillows\n\nPLAN: transfer to 708. transfer note sent. pt transfered via bed. tol well.\n\n\n" }, { "category": "ECG", "chartdate": "2196-11-12 00:00:00.000", "description": "Report", "row_id": 218394, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \naxis is less leftward. Tracing remains within normal limits.\n\n" }, { "category": "ECG", "chartdate": "2196-11-06 00:00:00.000", "description": "Report", "row_id": 218395, "text": "Sinus rhythm. Borderline left axis deviation. Possible left anterior\nfascicular block. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2150-12-29 00:00:00.000", "description": "Report", "row_id": 80007, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic dissection. Aortic valve disease. Congestive heart failure. Endocarditis. Left ventricular function. Prosthetic valve function. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 07:18\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No mass/thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. A catheter or pacing wire is seen in the RA and extending into\nthe RV.\n\nLEFT VENTRICLE: Severe regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; lateral apex - hypo; apex - hypo; remaining LV\nsegments are hypokinetic.\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis. Focal apical\nhypokinesis of RV free wall.\n\nAORTA: Ascending aortic intimal flap/dissection.. Aortic arch intimal\nflap/dissection. Descending aorta intimal flap/aortic dissection. Flow in\nfalse lumen.\n\nAORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Trace AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Physiologic (normal) PR.\n\nGENERAL COMMENTS: The post-bypass study was performed while the patient was\nreceiving vasoactive infusions (see Conclusions for listing of medications).\n\nConclusions:\nSee prior note for this case.\nPOST-CPB: Deteriorating LV function seen after AVR/aortic root repair. LVEF\nnow 15% with ant septal, ant, lateral mid and apical akinesis. AVR well-seated\nwith minimal stenosis and trivial regurgitation. RV systolic function is now\nmoderately depressed.\nLVAD in position with LA catheter 2 cm above level of mitral valve. Normal\nflow into aortic root graft. RV function now severely depressed on inotropic\nsupport. Mild TR.\n\n\n" }, { "category": "Echo", "chartdate": "2150-12-29 00:00:00.000", "description": "Report", "row_id": 80008, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative - ascending aortic dissection\nStatus: Inpatient\nDate/Time: at 12:34\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Mildly dilated LV cavity. Moderate-severe\nregional left ventricular systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall hypokinesis.\nSevere global RV free wall hypokinesis.\n\nAORTA: Markedly dilated ascending aorta. Mildly dilated descending aorta.\nAscending aortic intimal flap/dissection.. Aortic arch intimal\nflap/dissection. Descending aorta intimal flap/aortic dissection.\n\nAORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets.\nSevere (4+) AR. Eccentric AR jet.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPRE-CPB Left ventricular wall thicknesses are normal. The left ventricular\ncavity is mildly dilated. Overall left ventricular systolic function is mildly\ndepressed, EF = 40%. Resting regional wall motion abnormalities include severe\nhypokinesis of the distal anterior, distal septal, distal anterolateral walls\nand apex. The right ventricular cavity is dilated. There is moderate to severe\nglobal right ventricular free wall hypokinesis. The ascending aorta is\nmarkedly dilated The descending thoracic aorta is mildly dilated. A mobile\ndensity is seen in the ascending aorta consistent with an intimal flap/aortic\ndissection. The dissection extends throughout the aortic arch and as far down\nthe descending thoracic aorta as can be visualized. The aortic valve is\nbicuspid. The aortic valve leaflets are mildly thickened. Severe (4+) aortic\nregurgitation is seen. The aortic regurgitation jet is eccentric. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\na small pericardial effusion. There is a left pleural effusion.\n\nPOST-CPB Patient is receiving milrinone. Right ventricular function is\nimproved - now mild-moderate free wall hypokinesis, though apex appears more\nhypokinetic. Left ventriclular systolic function is also improved. EF=50%.\nStill some apical hypokinesis. LV appears underfilled. Aortic valve bileaflet\nprosthesis is very poorly seen. It appears well seated. Can not definitively\ndetermine if both leaflets are mobile, but there is no stenosis by continuity\nequation. There is at least trace AI, both valvular and perivalvular. Aortic\ngraft is in situ. Dissection flap is still evident in the aortic arch and\ndescending aorta.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2181-10-06 00:00:00.000", "description": "Report", "row_id": 1569836, "text": "Respiratory Care Note\nPt received on Hiflow O2. Unit dose Albuterol/Atrovent given via neb Q4. BS diminished with slight improvement after rx. Pt given PRN dose of Albuterol for increased SOB. ABG's at this time - respiratory acidosis with PaCO2 of 85. Pt placed on home Bipap machine - follow up ABG's improved with PaCO2 of 70. Plan to have pt wear Bipap more regularly.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-06 00:00:00.000", "description": "Report", "row_id": 1569837, "text": "pt remains in icu for resp distress with main issue being hycarbia.\n\nneuro : A&O mae oob most of day in lounge chair. pt does get more irratalbe with sats \n\nresp: on high flow until 1330 when placed to bipap for gas 7.23/ c02 81/ p02 69. pt also noted to havce inc twitching poss due to hypercarbia. gas improved to 7.30 co2 70 o2 61 onb bipap. bipap off for meals and given nc with int high flow for sat 78-80,s. will tol sat in 80\" s as pt is comfortable down to 70's and c/o being tired only when gas was 66 eating. pt needs bipap tonight\n\ncard stable bp and hr d/ced captopril and started lisinoprel.\n\ngi: had kexelate and only one hard bm this eve 1700 hem neg.\n\ngu: great u/o , goal 1000 cc neg and is currently neg 800 cc\n\nid: now cult shows MRSA and on precautions, needs vanco trough pre dose\n\nlabs: renal insufficiency and repeat k is pending. pt takes k-exalate well\n\nendo: glucoses still high and inc ssi humalog see flow sheet-\nplan: make set goal for sats and needs bipap tonight.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-07 00:00:00.000", "description": "Report", "row_id": 1569838, "text": "Progress Note 7p-7a\nEvents: At start of shift pt. placed on BIPAP. Pt. became confused/agitated, breathing in 40's and stating that he could not breath. Gas drawn : 7.17/88/130/0/34. Pt. given morphine 2mg and ativan 2mg to try to relax and calm him and bipap changes made. Another gas drawn: 7.09/102/158/1/37. Decision was made to intubate pt. After intubation pt. became hypotensive with sbp in high 60's and low 70's and bradycardic with rate in low 50's. 2L fluid given with no result. Dopamine hung and currently at 5mcg. Sedation off secondary to hypotension.R radial A-line, L IJ central line and NGT placed. Awaiting XRay confirmation of placement. Wife called and informed of pt.'s current condition.\n\nNeuro: Pt. appears to have had change in mental status since beginning of shift. He's lethargic/sleeping. No purposeful movement noted at this time. Pt. twitching at times. MDs aware. Responds to noxious stimulus. Pupils equal and reactive.\n\nResp: Pt. intubated and remains on ventilator. (please see careview for settings) Multiple changes made d/t multiple blood gas draws. Breath sounds diminished throughout at this time. Thick tan secretions noted with suctioning. Sputum sample sent to lab.\n\nCVS: Pt. SR/SB. SBP remains above 90 on 5mcgs of dopamine. R radial a-line placed with good waveform. Pulses difficutl to palpate secondary to 4+ pitting edema on trunk and extremities. Afebrile. AM labs pending\n\nGI: NGT placed. Abd. obese. BS hypoactive. Pt. NPO at this time. No BMthis shift.\n\nGU: Foley with sufficient urine output. Pt. continues to receive 80mg lasix . An additional 40mg IVP given wt 2100 with little effect.\n\nSkin: Intact. redness to bilat lower extremities.\n\nAccess: L IJ placed with CVP monitoring. Pt. also has 2 18g peripherals in L arm.\n\nPlan: ? CT of head for change in mental status, Monitor respiratory status and hemodynamic status closely. Adjust ventilator settings and dopamine gtt as needed. Also monitor renal function closely. BUN/creat rising slowly. Wife to be in to speak with doctors this am. Continue with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2181-10-07 00:00:00.000", "description": "Report", "row_id": 1569839, "text": "Resp: Pt rec'd on 60% h/f. Bs are coarse bilaterally with npc. HHN administered alb/atr.02 sats decreasing to 80's , abg reveals ^ in co2, pt placed on cpap with no improvement. Condition worsening, pt ^ wob, ^ sob. Placed on FFV psv 15/5/100%, abg's (see carview) again no improvement, pt was then intubated ett#8, 23 lip. Placed on A/C (see carview for settings) Xray reveals ett 5 cm above , ett advanced retaped and secured @ 27 lip. Suctioned for copious amounts of thick yellow/tan secretions. Sputum sample sent, possible bronch today?Pt continued to desat, then placed on APRV with increase in saturation. Vent settings; APRV PH37/PL0/TH2.0/TL0.5/100%. Will continue full vent support and titrate fio2 when appropriate. AM ABG pending.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-07 00:00:00.000", "description": "Report", "row_id": 1569840, "text": "Addendum to 7p-7a progress note\nPt. to have CT today. Also, please drav vanco trough before 1500 dose.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-07 00:00:00.000", "description": "Report", "row_id": 1569841, "text": "pt has been intubated <24 hr for resp distress MRSA PNA, pt has NKDA< hx copd,dm,\n\nneuro: pt ms has improved since am from unresponsive off to following all commands and agitated MAE, rolloing in bed noted at 1500 off . sedated pt with fent 25 mcg/ hr and midaxolam 1.5 mg/hr for current level of arousable to noxious stim. pupils PERL 3mm sluggish. unsure if ms improved with vent settings or recovery from .\n\ncard: hr 80-110 irreg nsr no pvc's, bp is maintained on dopamine 5.0 mcg/kg/min, adjusted and attempted to wean several times but unsuccessful due to need to sedate. hyporension poss due to fever spike and poss vascularly dry. given ns bolus 500 cc at 1700 but still needs dopa. iv fluid currently at kvo. lisinoprel and metoprolol held for bp issues. cvp after leveled and on cmv is 22\n\nresp: switched to CVM vent to allow more expiratory time and on 70% o2, peep10 /rate 23/ tv 550. copious amts green to brown chunky thick secretions several times suctioned using lavage. see blood gases\n\ngi: npo 10 cc residual , ng tube no bm and started on bowel regimen. would like to have bm prior to starting feedings as abd distended.\n\ngu: started voideing this am 0700 after hrs low output prob hypotension. currently 80-100 cc/hr and is pos fluid balance 2500 cc\n at this time. + edema in lower back and legs.\n\nskin: intact, total bath done 1200.mouth care done\n\nendo: all insulin doses reduced and glucose is currently 107 , no insulin this shift.\n\nid: temp spike to 103 rectal at 1700 and given 1 gm tylenol ng. pan cultured and iv fluid bolus given. hypotension noted mroe of issue with spike\n\naccess: 2 peripherial lt arm, central lt ij and rt a line all wnl\n\nrenal- repeated labs and bun 111 and creat 2.5\n\nplan: hold bp meds, wean dopa if poss maintain balance between and bp. will prob bronch . ct of head for ms change on hold for improed ms .\n" }, { "category": "Nursing/other", "chartdate": "2181-10-07 00:00:00.000", "description": "Report", "row_id": 1569842, "text": "Respiratory Care Note\nPt received on APRV as noted. BS diminished bilaterally. Pt suctioned for copious green/brown secretions throughout the shift. Pt placed on AC in preperation for Bronchoscopy - Bronch not done this shift. PIP's in low 30's with good chest expansion. Pt left on AC. Plan to remain on current mode of ventilation. Plan to aggressively suction pt and possibly Bronch tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-08 00:00:00.000", "description": "Report", "row_id": 1569843, "text": "Progress Note 7p-7a\nThis pt. was brought to MSICU for treatment of MRSA pneumonia. Intubated secondary to multiple poor blood gases despite bipap use.\n\nEvents: Pt. rested comfortably throughout shift. Dopamine weaned throughout shift VERY SLOWLY (1mcg every few hours). Pt. appears to be very sensitive to changes made in /pressors. Multiple ventilator setting changes made at beginning of shift d/t blood gas results (see careview).\n\nNeuro: Pt. sedated on 25 mcg fentanyl and 4mg versed. Appears to be resting comfortably at these settings. Pt. requiring small boluses after turning and bath. Pt. responds to stimuli. Nonpurposeful movement noted. Pupils equal and reactive. No pain issues at this time.\n\nCVS: Pt. remains in NSR at this time. SBP remained >95 systolic. Dopamine weaned slowly throughout night. Pt. remains on 5mcg/kg/min at this time (from 10mcg/kg/min at start of shift) R radial A-line in with sharp waveform. CVP ranging from 19-24. MDs aware. Pt. remains extremely edematous. (Receiving lasix 80mg ) Pt. pan-cultured yesterday for temp. spike of 103. 1 gram tylenole given at change of shift. Pt.'s temp slowly came down and now is 98.9 axillary.\n\nResp: Intubated. Multiple vent setting changes made throughout shift. Latest settings: CMV - 50/550/28/12. With suctioning pt. has extremely thick tan/green foul smelling secretions.\n\nGI: NGT in place. Pt. remains NPO at this time. Abd. obese. BS distant/hypoactive. No BM this shift.\n\nGU: Foley - great urine output. Approx. 200-500cc/hr. Clear yellow\n\nSkin: Intact\n\nAccess: L IJ triple lumen placed \n 2 18g peripheral IVs in L arm - patent\n\nID: Pt. remains on vanco, levaquin and flagyl\n\nPsychosocial: Pt.'s wife is healthcare proxy. She comes in everyday to visit. Pt.'s daughter and son in last night. All updated on pt.'s condition. Pt. wishes to remain full code at this time.\n\nPlan: Continue weaning dopamine as tolerated. Also, wean ventilator settings as tolerated. ? start tube feeds today? Monitor resp/cvs status closely. Continue with current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-08 00:00:00.000", "description": "Report", "row_id": 1569844, "text": "Resp: Pt remains on a/c 28/550/+12/50%. ETT #8, 27 lip. Vent changes made (see carview). BS auscultated reveal bilateral coarse sounds. Suctioned for copious, foul smelling thick secretions, yellow/greenish. MDI's administered Q4 hrs Alb/Atr. ABG 7.42/51/87/34. Plan to bronch pt today. Will continue full vent support.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-15 00:00:00.000", "description": "Report", "row_id": 1569871, "text": "Nursing note (1900-0700) 04:30\n\n\nNeuro.\nPt remains sedated on Fent 25mcg/hr, and 2mg/hr Versed. Pt trying to open eyes when stimulated, moving lower limbs bed at times, no movement in upper limbs as yet.\n\nResp.\nNo change in vent settings overnight, remains on AC/28/550/peep10/50%, SpO2 97-100%, abg acceptable. Pt sx'd for scant to moderate amounts of thick yellow sputum, some plugs lavaged this am.\n\nCVS.\nHR 80's A-flutter with occasional PVC's, and one 12 beat run of V-Tach, vitals remained stable, team aware, monitoring. Remains on Amiodarone.\nBP 80's-140's/50's-70's, Levo weaned to 0.05, attemted to wean further but MAP fell below 60mmHg.\nCVP 16-20.\n\nID.\nT-Max 99.1 overnight, now 95.9 ax, cooling blanket off. Pt continues on multi dose Abx. Fluconazole added for yeast in urine.\n\nGI/GU.\nTF's remain at goal of 50cc/hr, minimal residuals, Hypoactive BS with medium loose stool passed this am, sample sent for C-DIFF, guiacc negative.\nPt passing adequate amounts of yellow/cloudy urine via new foley.\n\nSkin.\nPt with generalised +3to4 pitting edema, scrotal area increasingly edematous. Pressure areas intact at present. Pt turned side to side as tollerated.\n\nSocial.\nCalled by family members, given update as to condition.\n\nPlan.\nWean Levo to off as able.\nWean Vent as able.\nMonitor for fevers.\n?? plan for dialysis line for acute renal failure.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-15 00:00:00.000", "description": "Report", "row_id": 1569872, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. BLBS are diminished. Sxn for thick yellow secretions. ABG shows compensated respiratory acidosis. No vent changes made. Auto-peep .\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2181-10-15 00:00:00.000", "description": "Report", "row_id": 1569873, "text": "BS rhonchi, fine crackles; no change with MDI's. Continuing to wean rate with mild hypercapnia.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-15 00:00:00.000", "description": "Report", "row_id": 1569874, "text": "Nursing Note 0700-1900\n\nEvents: Titrating levo to maintain MAP>60. Received 60mg IV Lasix x1 and will start on Lasix infusion.\n\nNeuro: Fent/Versed was turned off at 9AM to do a wake up. Remains unresponsive to voice; no spontaneous movements. At 1830 started on 0.5 Medaz. PEARLA @ 3mm and brisk\n\nResp: Vent settings-FiO2=40%, TV=550. Resp-decreased to 24, PEEP=10\nL/S were sl coarse in AM and clear in afternoon. Diminished sounds in bases. Suctioned for copious oral secretions.\n\nCV: Remains on Levo. which was titrated to maintain MAP>60. HR 79-97, Afib/Flutter with occ. PVC's. BP 87/45-131/58. CVP 16-18\n\nGI: TF set at 50ml /hr which is at goal. Residuals of 10-20mls, Abd. obese with hypoactive BS. No BM this shift.\n\nGU: Dark yellow with sediment draining via foley. Marked edema in extermities. Culture still pending\n\nEndo: Insulin gtt titrated to keep BS 80-120. FS 96-134\n\nSocial: Son, Wife and daughter in to visit.\n\nPlan: Continue to titrate pressors to maintain MAP > 60. Agressive oral suctioning. Keep family informed.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-29 00:00:00.000", "description": "Report", "row_id": 1569928, "text": "Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes overnoc maintaining compensated hypercarbia with marginal oxygenation; bs diminished, occ wheeze, sxn thick white/tan secretions, rx with mdi albuterol/atrovent mdi, rsbi 106, cuff press 40 cm to seal with positional leak.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-29 00:00:00.000", "description": "Report", "row_id": 1569930, "text": "MICU NURSING PROGRESS NOTE ADDENDUM 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Fs at 1600 was 65, rechecked at 1630 was 59. Medicated with 1/2 amp d50. At 1715 fs was 131. Team aware of drop in sugar, held 1600 nph per verbal order of team. Resting quietly in supine upright position. Intermittent cuff leak continues. Please place bipap on side table in am for pending transfer to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-29 00:00:00.000", "description": "Report", "row_id": 1569931, "text": "RESPIRATORY CARE: PT W/ 7.0 PORTEX DIC TRACH.\nREMAINS ON AC MODE AS PER CAREVUE. TRACHEAL\nCUFF PRESSURES HAVE BEEN MARGINALLY HIGH AT\n24-26 CM H2O W/ 11-12 CC OF VOLUME IN CUFF.\nD/W DR AND IT WAS DECIDED TO NOT\nCHANGE TRACH PRIOR TO DISCHARGE IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-30 00:00:00.000", "description": "Report", "row_id": 1569932, "text": "NPN 7p-7a\nNeuro: Pt appears alert at times, able to answer yes/no ?s, follows simple commands to squeeze hands, stick out tongue. Tmax 99.6PO.\nResp: Remains trached and vented overnight, requiring frequent (Q1hour) suctioning for thick white & yellow secretions, copious thin clear oral secretions too. LS: deminished t/o. O2 sats 92-93%.\nCV: A-line remains dampend, unable to draw labs this morning, utilized (R)AC mid line for labs. Pt rec'd 60mg IV lasix x1 w/good response.\nGI: Tube feeds via G-tube as ordered. ABD soft, BS+. Had 1 large brown OB- stool.\nGU: foley intact, clr yellow urine.\nPlan: to Rehab this morning, Mrs. called last evening and aware of plan.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-30 00:00:00.000", "description": "Report", "row_id": 1569933, "text": "BS coarse crackles; no change with MDI's. Pt continues with plentiful, thick, pale yellow secretions and is diaphoretic with temp to 100. Discharge held at this point pending evaluation of possible new sepsis. ? discharge tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-30 00:00:00.000", "description": "Report", "row_id": 1569934, "text": "Nursing note (0700-1900) 17:15\n\n\nNeuro.\nPt , moving limbs with purpose, no complaints of pain, able to answer yes/no questions, trying to mouth words also, follows simple commands.\n\nResp.\nNo vent changes made this shift, SpO2 90-97%, LS clear to coarse with diminished bases. Sx'd Q1-3HRS for thick yellow secretions, sample sent for C+S.\n\nCVS.\nHR 50's-90's SB-NSR, on Lopressor and Amiodarone. BP 90's-120's/40's-60's NIBP. A-Line removed this am as no longer working. Central line removed as possible source of new fever, tip sent for C+S.\n\nID.\nT-Max 100.0F oral, started on Vancomycin, PAN cultured, urine and sputum for C+S.\n\nGI/GU.\nTF's changed to Probalance, started at 20cc/hr with goal of 65cc/hr, minimal residuals, +BS with no BM as yet this shift.\nPt passing adequate amounts of clear yellow urine via foley, aim is for even balance this day.\n\nSkin.\nNo change in skin status during the day, dressing to Left hand left intact, general anasarca improving slowly.\n\nSocial.\nVisited by son this am, and wife at bedside presently, updated as to reason pt did not go to rehab today.\n\nDispo.\nPt will be accepted to in am if fever remains stable.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569822, "text": "11-11pm npn\nRESP: pt on bipap for a short time this am, 40% 10/10 , pt OOB to chair - eating lunch (in chair all evening - tol. well) placed on 6 l n/p while eating, O2 sats 84% placed on 50% venti mask, O2 sats 84-86% placed on 70% cool neb - O2 sats 87-91 rr~24 ABG checked on 70% cool neb ~ 126/54/7.38 FIO2 decreased to 60% pt SOB with any activity. lungs w/ decreased breath sounds, receiving albuterol/atrovent nebs q 4 hrs. Also on Tiotropium and Fluticasone-Salmetrol INH. to be placed on bipap overnight. on Methylprednisolone 125 mg IV q 8 hrs.\n\nCV/FLUIDS: BP stable 120-148/47 HR 88-100 ST no vea noted. pt receiving 80 mg IVP lasix - with good response. UP 100-150cc/hr pt negative 2 liters. CV echo~ nml EF, diastolic dysfunction\n\nNEURO: A+Ox3, cooperative, calm. pt states has restless leg syndrome. feels jittery from nebs.\n\nENDO: blood sugars not in good control. FS @ 12 pm~265, 5 pm FS 417 ~pt received 15 u regular insulin sq. FS @ 8 pm 453~ started on regular insulin gtt @ 4 u/hr. FS @ 9 pm 450 - pt received 5 units regular insulin IV X1. FS@ 10 pm 331 (gtt currently at 4 u/hr.) CONTINUE TO CHECK FS Q 1 HR.\n\nGI: Pt on low NA Diet, hrt healthy/diabetic diet. good appetite. no stool pt received K-exaylate for a K~5.6 repeat K~5.4\n\nGU: foley intact, draining clear, yellow urine.\n\nID: WBC 11.4 pt on Levofloxacin. CXR~ moderate CHF, left pleural effusion, bibasilar opacities.\n\nSKIN: very dry, lower extremities red, edematous LENI's negative\n\nIV LINES: new #20 placed left lower arm, right # 20 intact - good blood return.\n\nA: CHF/pneumonia, elevated BS,\n\nP: antibx, bipap, nebs, FS q 1 hr, continue w/ regular insulin gtt (adjust accordingly) OOB (pt does better)\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569823, "text": "nsg addendum: sputum cx sent, as well as 2nd blood culture.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569824, "text": "addendum:\n\nFS @ 10:45 pm 233 - pt on regular insulin gtt at 1 u/hr, FS at 11:15 pm 194 ~~ pt started on D51/2 NS @ 75 cc/hr, regular insulin gtt at 1u/hr. will continue to check FS q , than q 1 hour.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-17 00:00:00.000", "description": "Report", "row_id": 1569879, "text": "Micu nsg progress note\nNeuro- Remains sedated on versed/fent. Will intermittently open eyes to stimulation. No spontaneous movement noted. Pupils equal and briskly reactive.\nCardiac- Bp and hr stable on levo at .085mcg. Cont on lasix gtt at 10mg/hr with improving response ~100-120cc/hr. Total body anacarca noted. Pt weeping from arms/legs.\nResp- Intub/vented on ac 550x24 40% 8peep with abg 66/54/7.34. After et tube retaped pt with copious amts thick tan/yellow secretions. Suctioned q 2hrs for lg amts.\nGi- On goal tube feeds. Tolerating without problem. Cont on insulin gtt adjusted according to fs (see flow sheet) No stool.\nId T-max 99.6 ax on zosyn/flagal/linezolid/fluconazole. Cultures have been neg.\nPlan- Cont to diuresis with lasix gtt. Follow lytes and replace as needed. Cont pulmonary hygiene. Will need to address possible need for trach with family. ? attempt to wean levo.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-21 00:00:00.000", "description": "Report", "row_id": 1569896, "text": "Patient remains on mechanical ventilation,weaned on PSV X 3 hrs then returned to A/C due to severe resp acidosis.BS diminished,patient suctioned for copious amount of thick clear sputum.Treated with alb/atrovent;plan to peg and trch in near future,sedated on ativan will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-22 00:00:00.000", "description": "Report", "row_id": 1569897, "text": "Nursing Progress Note 1900-0700\n*Full Code\n\n*Allergies: NKDA\n\n*Access: RR A-Line, L Sub.Cl. Multi-lumen\n\n*Precautions: MRSA\n\nIn brief: Pt presented to EW w/ COPD exacerbation, SAT's in upper 70's on 6L NC (85% on 5L @home \"a few weeks ago\") Pt stated he had thick yellow sputum for about a week. Transfered to ICU for eval. Hx of Asthma, CHF, COPD and Diabetes.\n\nNeuro: Pt mildy sedated, arouses with stimulus. Does not follow commands but does respond to touch and retracts from pain. PEARL @4mm brisk accomodation to light. Pt moves all extremities spontaneously, but seems to move upper extremities more than lower, and moves right leg more than left.\n\nCardiac: NSR with occasion PVC's. HR 85-98, SBP 89-146 (occasional drop to 70-85), MAP 53-79 (occasional drop 45-60). Tx'd drop in BP w/ Levo. Responded appropriately, decreased Levo to maintain MAP > 65. Last Levo @ 0.06mcg/kg/min. Heparin 5000 U SC given @ 0000; awaiting PTT results. Pos. pedal pulses w/ doplar. 2 Units FFP given from 0400-0600.\n\nResp: Endotrach on vent (CMV) @ 40% O2. POX 92-99. Required sxn x 3 w/ scant white sputum. RR 22-25. LS remained coarse bilateral upper lobes and diminished bilateral lower lobes. ABG's not yet avail.\n\nGI/GU: Obese w/ pos. BS, no stool this shift (Colace and Biscodyl given). Tube feeds stopped @ 0000 as pt. is expected to go to OR for Trach and PEG in AM. Finger Sticks range 131-198, but last FS 89 so stopped Insulin gtt (since off TF). Foley collected 100-200cc/hr. On lasix @ 10ml/hr. +4 edema bilaterally upper and lower extremities and scrotum. Arms weeping copious yellow fluid. Labs not yet available for Electrolyte since MD's requested draw follow 2 Units FFP. Labs draw at 0600. weight 126.7kg.\n\nID: Temp range from 100.7-101.7. 650mg Acetaminophen given @ 0030 and 0515. MD's requested cultures (blood, urine, sputum sent).\n\nPsycosocial: Supportive common law wife, called to check on his status. Does not wish for him to be in a long term facility.\n\nDispo: Full Code. Continue Levo, Insulin, and Lasix gtts. Monitor MAP, I&O, and hourly BS. Adjust according to MD orders. Scheduled for Trach and PEG in AM.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-22 00:00:00.000", "description": "Report", "row_id": 1569898, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, no vent changes overnoc maintaining spo2 92-99%; bs diminished/coarse, sxn thick white secretions, rx with mdi albuterol/atrovent mdi, apneic for rsbi attempt, will full support until after trach.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-22 00:00:00.000", "description": "Report", "row_id": 1569899, "text": "Nursing 0700-1900\nEvents: Trach and Peg @ 1330 today. D/C Lasix AM. D/C Levo post OR.\nInitiated insulin @ 1600 D/T rising BG levels.\n\n\nMERSA precautions\n\nNeuro: Remained \"sedated\" throughout day, even though no sedations meds were initiated. Opens eyes to voice . PERLA ; 4mm; brisk accomodation\n\nResp: CMV 40%/550/8/22 O2sat 98-100% Lungs diminished on left(upper and lower) and clear on right. putum cultures pending. Sputum cultures pending. Trach draining sero sang. Performed trach care. Trach dressing changed @ 1800\n\nCV: NSR with rare ectopy noticed; Cap refill <3sec; HR: 79-91; SBP: 106/44-169/61; MAP 60-70's Levo adjusted to maintain MAP>65. Levo was D/c after returning from OR and maintained pressure. ++Pedal pulses via doppler.\n\nGI/GU:Peg procedure @ 1330. D/C lasix this AM and output continues to fall. 3+ pedal edema. + BS all quads. 3 bowel movements this AM-liquid in texture. Urine and Stool cultures pending\n\nSkin: Warm/dry; Oral ulcers. Yellow drainage from Left arm, wrapped in gauze.Temp: 100.4-97.9.\n\nSocial: Wife and daughter in to visit\n\nDispo: Full code\n\nPlan: Monitor Map and keep > 65\n FS q2hrs and adjust insulin PRN\n Continue I/O monitoring\n suction PRN for bloody trach drainage\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-23 00:00:00.000", "description": "Report", "row_id": 1569900, "text": "Nursing Progress Note 1900-0700\n*Full Code\n\n*Allergies: NKDA\n\n*Access: RR A-Line, L sub.cl. multi-lumen\n\n*Precautions: MRSA\n\nIn Brief: Pt presented to EW w/ COPD exacerbation, SAT's in upper 70's on 6L NC (85% on 5L @ home \"a few weeks ago\"). Pt stated he had thick yellow sputum for about a week. Ts'd to ICU for eval. Hx of Asthma, CHF, COPD and Diabetes. had Trach and PEG placement. Nothing in PEG for 24H.\n\nNeuro: Pt mildly sedated, arouses to pain, touch, sxn. Does not follow commands, retracts from pain. PEARL @ 4mm brisk accommodation to light. Pt moves all extremities spontaneously. Moves lower extremities more than upper.\n\nCardiac: NSR w/ occasional PVC's. HR 71-89, SBP 138-159, MAP 68-84 (occasional drop < 60, restarted Levo at low levels 0.020-0.030). Responded appropriately to Levo changes. Last level @ 0.020 maintain MAP >65. Pos. pedal pulses w/ doplar.\n\nResp: Trached . Vent settings 40%/550/8/22. Cuff pressure maxed out and is still leaking. Surgery notified by Respiratory. Plan to Bronch and replace w/ larger trach in AM. Currently maintaining respiratory status. Requires frequent oral and trach sxn (blood tinged sputum from both). RR 22-24. LS course bilateral upper lobes, diminished bilateral lower. ABG taken done @ 2100 d/t trach cuff issues: 7.40/58/67.\n\nNursing progress note . below\n" }, { "category": "Nursing/other", "chartdate": "2181-10-11 00:00:00.000", "description": "Report", "row_id": 1569858, "text": "RESP: BS'S CLEAR. SUCTIONED FOR TENACIOUS TAN THICK SPUTUM REQUIRING LAVAGE. O2 SATS 94-95%. PS TRIAL FAILED. PT. WILL PROBABLY REQUIRE A TRACH IN THE FUTURE. PT. WAS VERY O2 DEPENDENT AT HOME.\nGI: TOL TF'INGS AT 50CC/HR. FREE WATER BOLUSES CONT. NO STOOL TODAY. NEED C-DIFF SENT IF HE GOES.\nRENAL: CREAT 2.2. ADEQUATE U/O'S AFTER NEO INCREASED.\nCV: CONT. ON AMIODURONE TIL 15:30PM, BUT D/C AFTER PO DOSE GIVEN. NSR WITH OCCASS PAC'S. MAPS OVER 65. NEO IS TRIPLE CONCENTRATED. CVP 18. ? OF LEVOPHED IF U/O'S DROP OFF. VERY EDEMATOUS IN ALL EXTREMETIES.\nID: CONT. WITH LOW GRADE TEMPS. ANTIBIOTICS CONT. VANCO D/C'ED D/T HIGH TROUGH LEVEL. WILL BE DOSED QD.\nENDOC: INSULIN GTT AT 4U/HR. BS'S CHECKED Q2HRS.\nNEURO: CONT. ON FENT. AND VERSED. OPENS EYES TO COMMANDS. MOVING ARMS ONCE IN AWHILE. FOLLOWS SIMPLE COMMANDS.\nSOCIAL: WIFE WILL BE INTO VISIT LATER THIS AFTERNOON.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-29 00:00:00.000", "description": "Report", "row_id": 1569929, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Midline placed this pm. Pt in to evaluate pt. Pt has bed at sanai at ..\n\n Neuro: Responding to verbal stimulus, opening eyes and following simple commands. Napping for short periods and awakenes with minimal stimulus. Moving upper and lower extrem. on bed. Soft wrist restraints in place for safety. Temp. max. 99.5 oral. Phys. therapy redports that pt not following all her commands. Working with pt, will do eval for d/c.\n\n Respiratory: Lung sounds are diminished throughout. Ventilator settings a/c .40/550/14/8. See careview for most recent abg on present settings. O2 saturation on present settings 92-97% Suctioned every1-2 hrs for small to moderate amts of thick white to yellow sputum.\n\n CV: Sinus brady to sinus rhytym with no ectopy noted, rate 58-70. Abp 100's to 120's sytolic. A line site reddened, waveform dampended easily, can be difficult to draw labs. Lt sc qaud lumen site reddened. Dressings and caps changed, a line tubing changed. Mid line inserted by ivt. Was attempted picc line but did not work, midline will be good for rehab. Midline site was vbleeding, appears to have stopped. Hct 27.3, down from 29.\n\n GI/GU: Abdomen obese with + bs. Peg tube in place, tf at 40cc/hr, free h2o bolus 200cc every 6 hrs. One small soft brown bm.\n Foley catheter patent and draining clear yellow urine 30-50cc/hr\n\n Endo: Riss in use, no coverage required.\n\n Pt: Pt into evaluate pt\n\n Social: Wife in to see pt, aware of impending transfer.\n\n Plan: Transfer to rehab tomm at 10 am, bed is avail. Ensure paperwork complete. Monitor sputum and sent for cx if change in color is noted. Monitor abg and wean ventilaot as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-17 00:00:00.000", "description": "Report", "row_id": 1569880, "text": "day 11 intubated, remains full code\n\nneuro: stopped to weake pt and could follow simple commands after 90 min off but rest rate and rhythm off and is currently sedated with 25 mcg fent and .5 mg versed, PERL moving head on pillow.\n\ncard: remains in afib and ekg done today at bedside for routine. very dependent on levophed at .10 mcg/kg/min. increased levo to keep map at goal 70 now to profuse kidneys. sys 107-135 map > 70. hr 88-105 afib with occ. pvcs. discussed with house staff poss need to cardiovert out of afib. no decisions made just yet.\n\nresp: remains on same vent settings, sat 91-93. suctioned with lavage with sm to mod amt thick tan secretions. cxr this am showed worsened chf\n\ngi: had mod soft brown bm with ducolax suppository, hem neg and sent for c-diff which is thus far neg. tube feeds changed to full strength to decrease any free h2o intake and goal lowered to 40 cc/hr, no residuals when checked.\n\ngu/ fluid balance pt is slightly pos on 10 mg/hr lasix gtt and voiding 90-110 cc/hr. wt today with 1 pillow 1 chux and 1 sheet is 134.3 kg.\nsome brown sediment noted occasionally in urine, renal consulting.\n\nlabs HCT down and transtused 1 uprbc with out reaction. repeat lytes pending 1700 draw. as pt hyponatremic earlier today.\n\nid: no change in antibx. t max 99.6 at 1200.\n\nskin: small area on left calf posterior red and not open noted, buttucks one 1 cm area on lt buttuck is red and applied aloe cream and turned q3h. + pitting edema in lower back, feet and hands, lt arm and hand weeping serous fluid from open areas. freq change of chux and abd on arms\n\nendo: excellent glucose control on 3 units reg insulin qhr.\n\nsocial: wife insists that he will get better whem reviewed multisystem failure. may need to get whole family together. but they base his progress on last years illness when he was intubated for 3 wks.\n\n\nplan: follow up 1700 labs, resp hygiene, keep map at of above 70.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-11 00:00:00.000", "description": "Report", "row_id": 1569859, "text": " pm npn\nRESP: pt remains intubated and vented on AC 50%/550/20 peep~10 ABG checked ~65/53/7.36 O2 sats 93% pt suctioned q 2 hrs for thick tan secretions, lungs w/ coarse breath sounds.\n\nCV/FLUIDS: Neo gtt changed to Levophed gtt, bp 100-120/50 unable to wean gtt off, SBP drops to 70, HR~80's SR no vea noted. CVP~19 SVO2 checked after levophed started 73 (before svO2~69) Amiodarone gtt done - pt started on Amiodarone HCL 400 mg po BID,\n\nID: afebrile WBC 17.0 pt on Zosyn, Flagyl, Vanco (check level in am~ dose accordingly). Vanco level~26 stool C-diff negative, urine >100,000 yeast. blood cx's pending. pt on contact precautions ~MRSA pneumonia, COPD\n\nGI: tube feedings @ 50 cc/hr, free H20 flushes decreased to 50 cc q 6 hrs. no stool\n\nGU: foley draining cloudy yellow urine, UO~60-80 cchr bun~108 crt 2.2\n\nENDO: insulin gtt @ 4 units/hr. FS 112-124\n\nNEURO: pt remains sedated on a Fentanyl gtt @ 25 mcg/hr, Versed gtt @ 2 mg/hr, hands restrained for safety. pt w/ good cough, opens eyes to voice, nonpurposeful movements. +cough, +gag. (baseline pt A+Ox3, cooperative)\n\nA: resp failure, hypotension, fever, acute on chronic renal failure, hyperglycemia.\n\nP: continue w/ pulm toilet, change to pressure support as tolerated, continue , may need to change to Propofol (to wean off Fentanyl/Versed) continue Levophed (wean as tolerated), continue Amiodarone for rate control. continue antibx, check cultures, follow I+O's, lytes, pt is a full code.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-25 00:00:00.000", "description": "Report", "row_id": 1569913, "text": "Respiratory Care:\nPt remains on mechanical ventilation on PSV 14/8 40% w/rr = 28\nAnd Ve = ~11.5L sat = 95% will likley rest on A/C tonoc.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-26 00:00:00.000", "description": "Report", "row_id": 1569914, "text": "Resp Care Note, Pt rested overnight on A/C. Suctioned for mod amts thick white secretions.RSBI attempted on 0 peep/5 ips 146.MDI'S given . Will wean as tol today. to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-26 00:00:00.000", "description": "Report", "row_id": 1569915, "text": "NPN 1900-0700:\n\nEVENTS: Rested on CMV; continuing to diurese.\n\nROS:\nNEURO: Lethargic at times, MAE, f/c, mouths words, andswers yes/no questions. No needed.\nRESP: Rested on CMV overnight. Sxn q4 hours for thick white. Sats 92-98%, LS CTA upper, diminished lower.\nC-V: Remains hemodynamically stable with BP running on the high side; Lopressor to be increased with next dose. Lytes WNL.\nGI: Tolerating TF's at goal. Belly benign; med brown stool X 2, now looks/smells like ? c diff.\nGU: BUN/creat remain stable. TFB >1L positive at MN, but true fluid balance not so positive as much of the intake is free water. Given 40mg Lasix at 2200 with modest results.\nID: Afebrile, WBC WNL, off all abx. Sputum gm stain from shows 2+ GNR's; cx pending. As noted above, stool suspicious for c diff.\nENDO: Remains off insulin gtt but sugars are close to 300.\nSKIN: No new changes.\nHEME: No active issues.\nACCESS: A-line very positional; MLC site benign and line functioning fine.\nSOCIAL: Wife called for update; no visitors.\n\nA: stable night, but sugars running high\n\nP: Continue PS wean; OOB QD as able; needs tighter BS control; send stool for c diff; await final sputum cx; follow BP on increased lopressor dose; diurese as ordered; ? D/C a-line; continue rehab screening.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-14 00:00:00.000", "description": "Report", "row_id": 1569867, "text": "Nursing note (0700-1900) 04:20\n\nEVENTS:\nPt with asynchronous ventilation.\n stim test.\n\nNeuro.\nPt with increased due to ventilation issues, now on 50mcg/hr of Fent, and 4mg/hr of Versed, pt with minimal response to stimulation, will grimace to suctioning etc. no spontaneous movement noted.\n\nResp.\nPt with drop in sats after repositioning at 22:00, unrelieved with sx and lavage, ABG 7.29/65/68, and dysyncronous with vent, appeared to be trying to breath at rate of 40's-50's, though not actually pulling any air per vent readings. rate increased to 24BPM with no effect, further increased to 28BPM with resolution of resp acidosis, O2 increased to 60% also.\nLS coarse to UL's, diminished to LL's. Chest CT showed multi-lobar pneumonia per medical team. Thick yellow pluggy secretions continue in moderate amounts.\n\nCVS.\nHR 90's-120's NSR-ST with frequent PAC's, K+ 5.3 this am.\nBP. 110's-150's/50's-60's. Able to wean Levo down to 0.25mcg/kg/min, maintaining MAP >65.\nHCT stable, 30.2 this am.\n\nID.\nT-Max 101.4F oral. WCC ^ to 25.2 this am, continues on multiple abx, single dose of Linezolid given, awaiting ID approval for further doses.\n\nGI/GU.\nTF's continue at goal of 50cc/hr, minimal residuals, +BS with no BM as yet this shift, bowel regimen in place.\nPt passing variable amounts of yellow urine with sediment via foley, pt with +ve fluid balance of ~ 3.5L for last 24hrs. Will speak with team regarding possible dose of Lasix.\n\nEndo.\nPt with increasing requirement of insulin following stim test, currently increased to 8IU/hr, with FSG now in 200 range.\n\nSkin.\nno change in skin charachter this shift, arms elevated on pillows.\n\nSocial.\nWife called early in shift, given update at that time.\n\nPlan.\nMonitor fevers and FGS.\n? diurese.\nWean vent as able.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-14 00:00:00.000", "description": "Report", "row_id": 1569868, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. Increased RR to 28, FiO2 increased to 60% to stabilize ABG. BLBS are diminished. Sxn for thick yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2181-10-14 00:00:00.000", "description": "Report", "row_id": 1569869, "text": "resp care\nremains intub/vented on ac mode. abg pending. sxned initially for scant secretions, when cough stimulated sxned for mod thick yellow. mdi given q4h. chance of bronch tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-14 00:00:00.000", "description": "Report", "row_id": 1569870, "text": "M/SICU NPN FOR 7A-7P: FULL CODE NKDA\n\n PLEASE SEE FLOWSHEET FOR MORE DETAILS\n\nEVENTS: SLOWLY WEANING LEVOPHED GTT, CHANGED FOLEY AND RESENT URINE CX. SPUTUM CX RESENT. SPIKING TO 103.2 TODAY. COOLING BLANKET IN PLACE. RENAL CONSULTED AND SEEN. POSSIBLE CVVHD EARLY THIS WEEK, IF NOT RENAL FUNCTION DOES NOT IMPROVED. DECREASED DUE TO BECOMING UNAROUSABLE THIS AFTERNOON.\n\nNEURO: REMAINS FENTANYL/VERSED GTTS. PERLA 2MM BRISK. NO MOVEMENT NOTED TODAY. BILAT SOFT WRIST RESTRAINTS IN PLACE FOR SAFETY AND DUE DECREASING SEDATIVES.\n\nPULM: REMAINS ON SAME VENT SETTINGS A/C X 28, TV 550, PEEP 10, FIO DECREASED TO .50% DUE TO ABG RESULTS (7.35/51/159). LUNG SOUNDS COARSE IN UPPER LOBES AND DIMINISHED IN BASES. SUCTIONED Q2-3 HRS FOR THICK YELLOW SECRETIONS. SPUTUM CX RESENT TODAY PER MICU INTERNS REQUEST. ETT ADVANCED 2CC W/ REPEAT CHEST X-RAY DONE. NOT OVERBREATHING TODAY.\n\nCV: REMAINS IN AFLUTTER W/ FREQUENT PVC'S AT TIMES. ON LEVOPHED GTT AND WEANING AT PRESENT (GOAL MAP > 60). BP 107/53 - 134/63. SPIKED TO 103.2 W/ A TOTAL OF 1.5 GMS OF TYLENOL GIVEN AND COOLING BLANKET PLACED. BILAT UPPER AND LOWER EXT EDEMA STILL PRESENT W/ NO SIGN. CHANGE NOTED. PPP X 4. ROUTINE ECG DONE.\n\nGI/GU: ABD IS OBESE, SOFT, NT, ND. OGT IN PLACE W/ NEPHRO AT GOAL RATE (50CC/HR). RESIDUALS SLIGHTLY INCREASED FROM YESTERDAY TO MAX. OF 80CC X 1. NO BM A PRESENT. GIVEN DUCOLAX SP X 1 AND LACTULOSE VIA OGT X 1. FOLEY CHANGED PER ID'S REQUEST (14 FRENCH PLACED). CONTS WITH OLIGURIA TO 15CC/HR AT TIMES. URINE CX RESENT AFTER FOLEY REPLACEMENT.\n\nENDO: CONTS. ON INSULIN GTT AT 8 UNIT/HR W/ Q 2HR BLOOD GLUCOSE CHECKS.\n\nSKIN: NOTED FORESKIN AREA W/ YEAST. MICU INTERN IS AWARE. URINE + FOR YEAST. BRUISING TO LEFT HAND PRESENT W/ NO CHANGE. NO BREAKDOWN TO BACK-SIDED NOTED AT THIS TIME.\n\nPLAN: CONT. W/ CURRENT PLAN OF CARE. MONITOR PER PROTOCOL. 1600 LABS SENT AND AWAITING RESULTS. K+ AT 4.4 THIS AFTERNOON. CONT. WEAN VENT AND PRESSOR AS TOLERATED AND TITRATE INSULIN GTT AS NEEDED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-26 00:00:00.000", "description": "Report", "row_id": 1569916, "text": "Resp Care\n\nMode of ventilation changed to CPAP/PSV with a pressure of 14. First abg 7.40/57/67/37. After 6 hrs rr increase to 37-38. abg reveal 7.38/65/70/40. Psv increased to 18. BS diminished and suctioning thick yellow tan sputum and receiving bronchodilators\n" }, { "category": "Nursing/other", "chartdate": "2181-10-26 00:00:00.000", "description": "Report", "row_id": 1569917, "text": "S/MICU Nursing Progress Note\n Neuro: pt lethargic, will open eyes to name, mouthing words to yes/no questions. MAE,no required today.\n Cardiac: Hr intially 90-100's with BP 150-170/70's then received the next dose of lopressor of 25mg with good response, Now ranged 68-80's nsr rare APC, BP better and averaging 130-140/70's no lasix given yet today... is currently +600cc, wt down to 119kg. labs pnd.\n Respiratory: was on CMV changed to PS in the am, requiring 18cm of PS, when OOB to chair TV did increase to 400-500cc were able to drop PS to 14cm however RR up to mid 30's ABg oaky until 5hours later when ABG showed increasing CO2 to 65(from 57) increased PS back to 18cm. suctioned q 3-4hr for thick to mid white sputum.\n ID: afibrile, WBC 7.9 off all antibiotics.\n GI: on at 40cc/hr with fluid boluses 400cc q6hr. sm stool.\n Social: son and wife in to visit during the day aware of rehab screening. pt is now cleared for transfer to rehab. ?will not happen until Monday or Tuesday next week, family is requesting to have the pt go to .as it is closer to home.\n Plan: with weaning attempts. monitor I&O's with diuresis.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-28 00:00:00.000", "description": "Report", "row_id": 1569926, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Ventilator support increased. In chair for several hours today.\n\n Neuro: Easily arouses to verbal stimulus, appears alert and follows simple commands. Pupils 3mm and brisk. Able to move all extrem. weakly. Temperature max 99.2 oral.\n\n Respiratory: Lung sounds are clear in upper fields, dimished in lower fields bilat. Ventilator settings cmv/.40/550/14/8. Was on ps at 20 but had several episodes of tachypnea despite suctioning and lavaging, ambuing and repositioning. Abg on present settings 7.44/59/84/41. Team aware of abg and increased vent. support. Suctioned every1-2 hrs for scant to moderate amts of thick yellow/tan secretions. O2 saturation on present settings 95-99%.\n\n CV: Sinus brady to sinus rhythm with no ectopy noted, rate 50's to 90's. Abp low 110's to 140's systolic. A line site wnl, waveform occn. dampened. Difficult to draw blood. Lt sc qaud site slightly reddened at insertion site. Lasix 60 mg iv for fluid removal at 1630.\n\n Gi/Gu: Abdomen obese with + bs. Peg tube in place, fs at goal 40cc/hr. No bm this shift. Free h2o bolus decreased to 200 cc/hr. Foley catheter patent and draining clear yellow urine 40-90cc/hr.\n\n Endo: No coverage required today, fs 147 and 111 respectively. Standing dose is unchanged.\n\n Id: No abx as of this time.\n\n Social: Wife in for several hours this pm, son into visit also.\n\n Plan: Monitor urine output, goal is 1 liter negative. Attempt to wean ventilator settings slowly.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-29 00:00:00.000", "description": "Report", "row_id": 1569927, "text": "NPN 1900-0700\nNeuro: Lethargic, opens eyes to verbal stimulus, follows commands, moves all extremities in bed slept most of night, wrist restraints intact for safety.'\n\nResp: Lungs diminished throughout, resp. unlabored, sx'd moderate amts of thick white secretions per ETT q 1-2hrs., moderate thin white secretions sx'd per mouth q 1-2hrs. Continues on AC/.40/550/14/8 with O2 sats 89-92%, ABG 7.45/59/62/42.\n\nCV: HR 65-82 NSR, no ectopy, BP's 121-169/50-90's, given additional 12.5mg Metoprolol overnight, increased to 50mg Metoprolol . Given 60mg Lasix at 0430 to attempt diureses of -1L. T max 98.7.\n\nEndo: FBS 112-126, no SSI required.\n\nGI: BS (+), abd obese, x1 stool smear, unable to obtain sample for C-diff. Will give lactulose at 0600.\n\nGU: Foley intact draining clear yellow urine in adequate amts.\n\nSkin: Intact. Ulcerations on lips which are scabbed.\n\nPlan: continue to monitor resp status, obtain ABG in at 0800, wean as tolerated, transfer to rehab. when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-05 00:00:00.000", "description": "Report", "row_id": 1569831, "text": "Respiratory Care Note\nPt received on Hiflo aerosol with sats ranging 91-95%. Pt placed on home Bipap for several hours with sats ranging 88-92%. Pt given unit dose Albuterol/Atrovent via neb. BS diminished throughout with slight increase in aeration after rx; aeration improved slightly with Bipap also.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-10 00:00:00.000", "description": "Report", "row_id": 1569852, "text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT REMAINS SEDATED ON FENTANYL @ 25 MCG/HOUR AND VERSED @ 4 MG/HOUR. OPENS EYES TO VOICE. NOT FOLLOWING COMMANDS, LOCALIZES PAIN. DECREASED COUGH/GAG. PUPILS EQUAL/REACTIVE.\n\nCV: TMAX 99.4 (AX) HR 70-80 NSR WITH RARE PACS. PT REMAINS ON LEVOPHED GTT @ 0.04 MCG/KG/MIN BP 98-118/49-58. WILL CONT TO TITRATE GTT TO KEEP MAPS >60. CVP 14-15. +3 BILAT LE PITTING EDEMA + 2 BILAT UPPER EXT PITTING EDEMA. PT TREATED WITH ADDITIONAL LASIX 60 MG IVP (TOTAL OF 100 MG LASIX ) WITH LITTLE RESULTS. PT I&OS REMAIN POSITIVE, MD AWARE.\n\nPULM: PT REMAINS INTUBATED ON AC-22 50% TV 550 PEEP 10. RR INCREASED FROM 20 TO 22 AFTER EVENING ABG RESULTS 7.37/62/99. WILL REPEAT ABG WITH AM LABS. SATS 89-95%. LUNGS COARSE AND DECREASED @ BASES BILAT. SUCTIONING MOD THICK TAN SECRETIONS VIA ETT.\n\nGI/GU: ABD OBESE WITH HYPOACTIVE BOWEL SOUNDS. PT TREATED WITH FLEETS ENEMA X 1. PT HAD LARGE SOFT BROWN STOOL, GUIAC NEGATIVE SPECIMEN SENT FOR C-DIFF. PT TOLERATING @ 30CC/HOUR (GOAL 50CC/HOUR) VIA OGT WITHOUT DIFFICULTY, MINIMAL RESIDUAL NOTED. ALSO RECEIVING FREE WATER FLUSHES 400CC Q 6 HOURS FOR HYPERNATREMIA. FOLEY DRAINING YELLOW/CLEAR URINE. GOAL I& O EVEN. PT REMAINS + 2564 CC FOR 24 HOUR NET BALANCE, MD AWARE.\n\nENDOCRINE: INSULIN GTT @ 4 UNITS/HOUR. CONT TO CHECK FINGERSTICKS Q 1 HOUR AND TITRATE GTT PER PROTOCOL.\n\nPLAN: CONT TO WEAN VENT AS TOLERATED AND FOLLOW ABGS, PULMONARY TOILET, DIURESIS, WEAN LEVOPHED TO KEEP MAPS > 60, CONT TO MAINTAIN PT COMFORT, CONT INSULIN GTT, ADVANCE TF AS TOLERATED TO GOAL, WILL CONT TO MONITOR.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-10 00:00:00.000", "description": "Report", "row_id": 1569853, "text": "RESPIRATORY CARE\nRemains intubated and ventilated on a/c, settings as per flowsheets. Oxygenation/sats adequate on peep of 10. ABGs with compensated resp acidosis. Suctioned for very thick tan sputum. Plan to maintain ventilation,wean when able.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-10 00:00:00.000", "description": "Report", "row_id": 1569854, "text": "Resp CAre\n\nPt remains intubated and on full vent support. Attempted to wean pt to Cpap/Psv. Pt began to auto-peep and vent would not cycle with each\neach breath. Was than changed to A/C. Abg are stable on full vent support. Suctioning very thick yellow sputum. BS are generally diminished\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-10 00:00:00.000", "description": "Report", "row_id": 1569855, "text": "events : tachycardia with afib and hypo/hypertension, breaking at times and tx with several interventions.\n\nneuro: currently off cont since 1200 and has recieved fent 30 mcg ivp at 1645 and midaz 1.5 mg at 1530. arousable but not very active. can MAE, and did follow commands. at 1600. pupils 2-3 mm and brisk PERL goal was to decrease and trial on ps venbt but very dyscyn. and can sedate as needed.\n\ncv: episodes of tachy cardia and afib started at 0745 while potasium infusing. tx with 5 mg lopressor and stopped levo for bp in 180's. in 20 min bp dropped to 80 and stopped and after 1 hr of manipulation of meds bp settled to 105-120 and hr 60-80 nsr. second iv potassium 20 meq started and same tachy and htn with afib noted again. stopped potassium. rate broke on own but at 1200 got tachy again and given 2.56 mg lopressor and changed levo to neo to support bp. amioderone started to load at 1510 and currently infusing at 1mg/min x6 hr and then see med order for next infusion.\ncurrently on 1.5 mcg/kg/min neo and bp 90-116 with map >60, hr 112-135 afib alt with tachycardia and fev pvcs. bp dropping with afib and did not respond to bolus of 250 cc ns x2, had to inc neo.\n\nresp: on cmv with 50 % o2/ rate 22 10 peep 55 tv. last gas this am. sat 93-94. trial of ps as noted above when pt was very alert but failed . cont with mod tan thick secretions wiuth suctioning.\n\ngi: smear bm today stool neg guiac. tube feeds changed to 3/4 strength oo to give more h2o. cont with free h2o 200 cc q 3hr per ng. low residuals. tube feed at goal , hypoactive bs.\n\ngu: lasix po given pos balance of >500 cc this shift. urine cloudy and cult sent.\n\nid: t max 101.6 at 1400 and given 650 mg tylenol. pan cultured. levoflox stopped and flagyl changed to iv\n\nendo: glucoses were in good range and stopped insulin due to need to use lines and glu inc to 178 and 210. currently infusing insulin at 5 units/hr. all prednisone stopped.\n\nskin: mouth care done and position changed x2. lt lower leg feels warmer than rt. noted 1 cm wound with yellow/green base on back of calf lt lg will make md aware.\n\nlabs: repeat crit 31.8 and stool neg as was concern of poss bleeding this am.\n\nplan: sedate as needed control hr with amioderone loading. cont support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-11 00:00:00.000", "description": "Report", "row_id": 1569856, "text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: RECEIVED PT OFF , SON VISITED AND PT BECAME VERY AGITATED IN BED, DYSYNCHRONOUS WITH VENT. RESTARTED, FENTANYL CURRENTLY @ 25 MCG/HOUR AND VERSED @ 3 MG/HOUR. PT OPENS EYES TO VOICE, LOCALIZES PAIN. NONPURPOSEFUL MOVEMENT OF EXTREMITIES. PUPILS EQUAL/SLUGGISHLY REACTIVE BILAT. + COUGH/GAG REFLEXES. PRIOR TO THE RESTART OF , PT WAS FOLLOWING COMMANDS AND ALERT.\n\nCV: PT SPIKED TEMP ON DAYSHIFT AND WAS PAN CULTURED. TMAX OVERNIGHT 100.0 (AX), PT TREATED WITH TYLENOL 650 MG. HR CURRENTLY 70-80S SR WITH OCC PACS. EARLIER IN SHIFT PT WAS FREQUENTLY FLIPPING IN AND OUT OF A-FLUTTER-->NSR. PT REMAINS ON AMIO GTT @ 0.5 MG/MIN, THE 18 HOUR AMIO INFUSION WILL COMPLETE AT 1530. NEO GTT @ 1.75 MCG/KG/MIN, MAPS REMAIN > 60 WILL TITRATE AS TOLERATED. HCT STABLE @ 31.8. NEW LEFT SUBCLAVIAN QUAD LUMEN PLACED, ALL LINES CHANGED. BLUE PORT ON NEW LINE CLOTTED OFF, ALTEPASE 1 MG GIVEN WITH 1 HOUR DWELL TIME WITH GOOD RESULTS. OLD LEFT IJ LINE D/C AND TIP SENT FOR CULTURE, RESULTS PENDING. + 3 GENERALIZED ANASARCA, +1 PEDAL PULSES BILAT.\n\nPULM: PT REMAINS INTUBATED ON AC-22 FIO2 50% TV 550 PEEP 10. SATS 92-95% LUNGS COARSE AND DECREASED @ BASES BILAT. SX MOD THICK TAN SECRETIONS VIA ETT AND LARGE AMOUNTS OF ORAL SECRETIONS.\n\nGI/GU: ABD OBESE + BOWEL SOUNDS. PT HAD LARGE SOFT BROWN STOOL, GUIAC NEGATIVE. TUBE FEEDS CHANGED TO 3/4 STRENGTH SECONDARY TO HYPERNATREMIA. TF INFUSING @ 50CC/HOUR (GOAL) WITHOUT DIFFICULT, MINIMAL RESIDUALS. CONT TO RECEIVE FREE WATER BOLUSES. FOLEY DRAINING YELLOW/CLOUDY URINE. UO 40-60CC/HOUR.\n\nEMDOCRINE: PT ON INSULIN GTT @ 4 UNITS/HOUR. CONT TO CHECK FINGERSTICKS Q 1 HOUR AND TITRATE PER PROTOCOL.\n\nPLAN: WEAN VENT AS TOLERATED, CONT FOR PT COMFORT, WEAN NEO TO KEEP MAPS > 60, CONT ANTIBIOTICS, PULM TOILET, CONT AMIO GTT FOR A-FLUTTER, FOLLOW CULTURES, WILL CONT TO MONITOR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-11 00:00:00.000", "description": "Report", "row_id": 1569857, "text": "Respiratory Care Note:\n Patient remains orally intubated and on ventilatory support. see carevue for current settings. No changes made this shift to vent settings. SX'd for a moderate amount of yellow/tan thick secretions, lavaged several times. BS are coarse/diminished throughout. peak/plat 37/24 respectively. MDI's administered as ordered. No ABG this am due to peep level of 10. Will continue to monitor and wean when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-05 00:00:00.000", "description": "Report", "row_id": 1569832, "text": "pt still in icu for a pleural tap this afternoon.\n\nneuro: A&O x3 slightly anxious with resp effort, albe to stand with minimal assistance. pt dangled most of day.\n\nresp: switched to bipap for co2 33 this am and on for approx 3 hr with sat dropped to 88-92% pt in no inc distress on bipap. gas done on bipap o2 46 co2 64 and ph 7.38 switched to 60% high flow o2 to eat with nc . and currently on hi flow 60% with sat 95-96. sat drops with mask off to 79%. cult pos for staph pna and antibx changed to vanco. pleural tap for effusion lt side at 1645\n\ncard: bp 130-165 sys started on captopril and metoprolol. hr nsr 90-105 with exertion.\n\nendo: glucose still high off iv insulin given several doses reg insulin to cover and now ordered for humalog SSI coverage qid.\nwill start to decrease steroids \n\ngi: eating well despite resp distress and coughing with some intake.\nno bm bs pos. started ppi\n\ngu: lasix changed to po balance for 24 h is neg 1600 cc. serum na up a bit and poss vasc a bit dry. foley draining with lg output\n\nlabs: b 12 level low and iron low and starte on b 12 supplement.\n skin: back bathed, noted red area on lt upper back 1.5 x1.5 cm raised no drainage\n\nplan: post pleural tap eval resp status. maintain good glucose control. poss bipap as did seem to open airways with bipap.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-06 00:00:00.000", "description": "Report", "row_id": 1569833, "text": "NPN 1900-0700\nNeuro: Pt. alert and oriented x3. Pleasant and cooperative with treatment and care. Pt. restless ? s/s of high dose steorids.\n\nResp: Pt.'s resp. status improved s/p pleural tap on . No episodes of resp. distress or desaturation this shift. Pt. remains on 60% hi flow mask maintaining O2 sat mid to high 90's. Occ non productive cough. No ABG this shift.\n\nCV: Pt. started on metoprolol and captopril to maintain adequate kidney function. BR 100-160's/40-60's. HR 60-90's NSR with rare PVCs noted. Bil. ext. pitting edema +4 noted, unchaged from yesterday.\n\nGI: Tolerating diet well. ABd. obese soft, BS+. No BM this shift. Pt. with increased glucose > 300 on evening, Insulin changed to Humolog with coverage before meals and at bedtime. Pt. also on Lantus insulin.\n\nGU: Foley cath in and drainign adequate amounts of clear yellow urine. and creatnine elevate. Creat upto 2.0. Will recheck with AM labs.\nFluid status -.29L for 24 hr and -9.8L for LOS. Po intake small frequent sips of water.\n\nID: Pt. cont. on IV Vanco for staph pna. Afebrale.\n\nSocial; Pt. is a full code. No visitors this shift. Will cont. to update Pt. and family on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-06 00:00:00.000", "description": "Report", "row_id": 1569834, "text": "Resp: Pt remains on HF @ 60% with sats @ 93-96%. Improvement noted today following PE tap yesterday. HHN administered Q4 Alb/Atr with improvement noted. Will continue on present therapy. NPC\n" }, { "category": "Nursing/other", "chartdate": "2181-10-06 00:00:00.000", "description": "Report", "row_id": 1569835, "text": "Addendum\nCV: K 5.3 this AM. Lab repeated and awaiting results. Order for K exelate x1.\n\nGI: No BM foe several days. Pt. started on Senna PRN given at 0600 and COlace .\n" }, { "category": "Nursing/other", "chartdate": "2181-10-21 00:00:00.000", "description": "Report", "row_id": 1569894, "text": "Resp Care: Pt continues intubated and on ventilatory support with a/c, sedated but appears dys-synchronous when awake maintaining compensated hypercarbia with acceptable oxygenation; bs diminished with episodic exp wheeze, sxn white/yell secretions, rx with mdi albuterol/atrovent, rsbi 170, will support.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-25 00:00:00.000", "description": "Report", "row_id": 1569911, "text": "NPN 1900-0700:\n\nEVENTS: Placed back on CMV at MN to rest; diuresed further.\n\nROS:\nNEURO: Pt remains somnolent but easily aroused. F/C inconsistently; no attempts to communicate; MAE. No required.\nRESP: PS further weaned to 16 for the evening; he remained on 16/8/.4 until MN when he was placed back on CMV to rest. Prior to vent change pt had become more tachypneic, relatively hypertensive, with sats decreasing to low 90's. He has been comfortable on CMV all night. Suctioned q4 hours for sticky white secretions; minimal oral secretions. LS coarse upper, diminished lower. Intermittent positional cuff leak persists.\nC-V: Remains hemodynamically stable off pressors. K repleted last evening; AM lytes pending.\nGI: Tolerating TF's at goal; given scheduled bowel meds, but no stool overnight. Belly benign.\nGU: BUN/creat elevated but stable. UO 40-70cc/hr; given 40mg Lasix with modest results. TFB -800cc's at MN, plus insensible losses d/t weeping arms.\nENDO: Insulin gtt titrated for goal BS 80-100; on dose of 3u/hr most of night.\nHEME: Hct stable at 27.2; INR 1.3, plt WNL. No evidence of active bleeding.\nID: Low-grade temp; sputum spec sent; WBC WNL.\nSKIN: Weeping seems to have decreased. Intact purple bullae on L hand covered w/DSD. PEG site C/D, covered w/DSD. Trach site w/minimal bloody drainage. Skin otherwise intact.\nACCESS: LSC MLC; R radial a-line which is positional at times.\nSOCIAL: Son visited; wife and other son called for updates.\n\nA: stable night\n\nP: continue slow wean as tolerated; consider changing over to SSRI now that he is stable on goal TF rate; continue rehab screening.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-25 00:00:00.000", "description": "Report", "row_id": 1569912, "text": "S/MICU Nursing Progress Note 07:00-19:00\nSee Careview for Additional Objective Data\n#1:Respiratory Failure: COPD, CHF\nD:Denies SOB\n Remains trached and mechanically ventilated, fully supported on CMV mode with FiO2:.4, rate:14/min. SRR:0-10/min MV:/min SpO2:92-98% Suctioned q 2-4 hours for thick tan, now yellow sputum. Mucous plug x2 BS:coarse anteriorly and diminished.\n Tmax:99.9, not receiving antibx\n Hemodynamically stable\n Lethargic most of shift sleeping in bed and chair, wakens easily and nods appropriately to questions. Follows commands consistently\n Insulin gtt at 3 units/hr w/ BS:135-147\n BUN/CR:61/1.5 U/O:approx 30-90cc/hr I/O's by 15:00 +400cc, CVP this am:13. Na:145, K:3.5, Mg:2.5, Ca:8.8 and PO4:2.3\n Abd obese, soft with +BS. Patient denies and nausea, tolerating FS TF without issues. Large soft OB negative loose stool this afternoon.\n Spouse called this am, son in this afternoon for a brief visit. Patient and family updated on plan of care.\n\nA:Vent mode changed to CPAP+PS: 14 PSV, 8 PEEP\n Lasix 40mg IV\n KCL and KPO4 \n Insulin gtt D/C'ed, SC doses ordered\n OOB to chair x 3 hours via lift\n Increased free water boluses with rising Na\n\nR:Tolerated some weaning efforts, though he did begin to get tired w/ increase in RR:mid 30's, BP up to 180's/ after 2 hours.,rest on CMV overnoc and continue with weaning efforts in the am, beginning to diurese with IV lasix, goal - 1L qd, repleate electrolytes prn, Tolerated activity to chair, continue to get OOB qd, follow BS QID dose with NPH and cover q 6 hours with SS regular, Continue to update pt/family on POC qd\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-21 00:00:00.000", "description": "Report", "row_id": 1569895, "text": "MSICU NPN FOR 7A -7P FULL CODE\n\n PLEASE SEE FLOWSHEET FOR MORE DETAILS\n\nLINES/EVENTS: CENTRAL LINE TO LSVC AND R RAD A-LINE. REC'D 1 UNIT OF PRBC FOR HCT 26.\n\n\nNEURO:\n\nNO IV GTT SEDATIVES ORDERED. GIVEN ATIVAN 2MG TOTAL IV FOR COMFORT AND INCREASE IN RR. PERLA AT 3MM. MAE. BILAT SOFT WRIST RESTRAINTS IN PLACE.\n\nPULM: REMAINS ORALLY INTUBATED AND SCHEDULED FOR TRACH/PEG ON MON. CPAP + PS TRIAL DONE TODAY, BUT FAILED AFTER 2HRS (ABG 7.27/81/80/39). PLACED CMV X 22, TV 550, FIO2 .40%, PEEP 8. ABG ON THESE SETTINGS: 7.38/54/84/35. SUCTIONED Q2-3HR FOR THICK WHITISH TO CLEAR SECRETIONS. LUNGS ARE CLEAR IN UPPER LOBES AND DIMINISHED THROUHGOUT. O2 SATS 90-94%.\n\nCV: NSR W/ FREQUENT PVC'S AT TIMES. BP LABILE ON LEVOPHED GTT TITRATING TO KEEP MAP > 65. CURRENTLY INFUSING AT 0.03MCG/KG/MIN.\nCONTS. W/ LOW GRADE FEVER W/ T-MAX 100.3. CONTS. ON LASIX GTT AT 10MG/HR W/ GROSS AMT OF BODY +3 PITTING EDEMA. WEEPEING SEROUS FLUID FROM BOTH ARE IN MODERATES. WT IS DOWN TO 127 KG. (ADMITTING WT. 128 KG).\n\nGI/GU: + BS NOTED. OGT IN PLACE W/ TF'ING OF NEPHRO FS AT 40CC/HR (MIN. RESIDUALS NOTED). INCONT. OF SMALL LOOSE STOOL X 1. OB -. ABD IS OBESE, SOFT, NT. FOLEY IN PLACE W/ ADEQUATE UO TO > 200CC/HR AT TIMES.\n\nSKIN: EDEMA CONTS TO UPPER/LOWER EXTS W/ SOME MILD IMPROVEMENT. SCROTAL AND PENIAL AREAS SWOLLEN, AS WELL. ALSO, NOTED SMALL SUPERFICIAL ABRASION X 2 TO COCCYX AREA.\n\nENDO: OFF INSULIN GTT AT THIS TIME DUE TO BG AT 70. WILL RE-EVALUATE AT 1700. FINGERSTICK HAVE RANGED IN THE 70-110'S TODAY.\n\nPLAN: . W/ CURRENT PLAN OF CARE. MONITOR PER PROTOCOL. ATTEMPT TO WEAN LEVOPHED GTT AT TOLERATED TO KEEP MAP > 65. REPLETING ELECTROYTES AS NEEDED.\n\n-ANESTHESIA IN TO CONSENT FOR .\n-SCHEDULED FOR TRACH/PEG IN OR FOR \n-\n" }, { "category": "Nursing/other", "chartdate": "2181-10-13 00:00:00.000", "description": "Report", "row_id": 1569863, "text": "Nursing Progress note 1900-0700\nEvents: HR/BP remain labile, on pressor.\n\nReview of Systems:\n\nNeuro: Sedated on Versed 3mg/hr(increased from 2mg/hr after BP/HR spont increased), Fentanyl 25mcg/hr. Pt unresponsive to voice, no spont movement seen. PEARL @ 3mm and brisk, but pt not opening eyes.\n\nResp: No change in vent settings AC 50%/20 X 550/+10, with rare spont effort to rate 22. O2 sat 95-97%. Lung snds clear->coarse, diminished @ bases. Suctionned for small-mod amts thick yellow secretions.\n\nCV: Pt remains on Levophed, titrated from 0.158->0.2mcg/kg/min to maintain MAP>65. HR 95-112 Afib/flutter with occas PVC's. BP 96/51-125/58. Rare spont increase in HR to 120's and SBP to 160, returning to baseline spont after a few minutes. BP dropped to 70's when pt turned to R side, but tolerated turning to L. AM labs pndg.\n\nGI: TF of 3/4str cont @ goal 50ml/hr via OGT with residuals 20-30mls. Abd obese with distant bowel snds. No BM this shift.\n\nGU: Urine yellow with sed, draining via foley @ 22-60ml/hr. 24hr fluid balance @ MN +1.6liters, with LOS balance -955ml. Marked edema in extremeties persists. CVP 16.\n\nEndo: Insulin qtts cont @ 4units/hr, with FSG 111-117.\n\nSocial: Wife called, asked that nurse \"make pt better\".\n\nPlan: Cont to titrate pressor to maintain MAP>65. Repeat Vanco trough. Cont aggressive pulm toilet. Team mtg with wife/family to be scheduled.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-13 00:00:00.000", "description": "Report", "row_id": 1569864, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. No vent changes made during the noc. BLBS are coarse with some crackles. Sxn for thick moderate amount yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2181-10-13 00:00:00.000", "description": "Report", "row_id": 1569865, "text": "resp care\nremains intub/vented in ac mode. occ spont efforts..usually not triggering vent successfully. bs rhonchorous. sxning thick yellow with lg amt oral secretions. transported to ctscan, vent status stable t/out. mdi given q4h. c/w vent support d/t fluid overload,sepsis.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569818, "text": "Progress Note 7p-7a\nThis pt. arrived from EW at 2200. Pt. has PMH of COPD, CHF, DM, OSA with bipap use and asthma. Pt. presented to EW with increased SOB and sats in high 70's. ?COPD exacerbation vs. pneumonia. Brought here to ICU for further eval and treatment.\n\nNeuro: Pt. alert and oriented x3. MAE. Pupils equal and reactive. No pain issues. No neuro deficits.\n\nResp: Pt. remains on BIPAP at this time. (He brought in his machine from home)Settings: (s)/22/10/6. Breath sounds coarse bilat with rhonchi bilat. Pt. states that he has been coughing up \"thick yellow stuff\" for the past week. Unable to attain sputum culture at this time. Pt. appears SOB with exertion and when mask removed, sats drop rapidly to 70's.\n\nCVS: Pt. SR/ST without ectopy. SBP remains WNL. + pulses. + pitting edema noted in lower extremities. Generalized edema in bilat upper extremities. Afebrile at this time.\n\nGI: Pt. remains NPO at this time. Abd. lg./obese. Bowel sounds distant/hypoactive. No BM this shift.\n\nGU: Foley with yellow uring. approx. 100cc/hr out. Pt. receiving 100mg lasix .\n\nSkin: Bilat. lower extremities red/hot to touch. MDs aware.\n\nAccess: 18g in each forearm patent. No IVFs at this time.\n\nPlan: attempt to wean pt. off bipap as tolerated. According to pt., he is on 4-5L NC at home. Attain sputume culture to r/o pneumonia. Please attempt to attain that. Also, collect 2 out of 2 blood cultures. Monitor resp/cardio status closely.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569819, "text": "addendum to 7p-7a Progress Note\nAM labs pending. Pt. to have echo this am.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569820, "text": "Respiratory Care:\n\nPatient admitted from ER with Pna/Copd/Asthma Exacerbation. Pmhx: Copd/Asthma, OSA(home Bipap/O2). Uses MDI's/Nebs at home. Pt initially requiring NRM alternating with home Bipap to maintain O2 sats. Settings Ipap 22/Epap 10, with 6lpm 02. Pt. uses 5lpm 02 at home. Albuterol/Atrovent Nebs given Q3hr with good response. RR 16-22. Bs decreased with crackles L base. Increased aeration over course of shift. O2 sats improving and patient weand to 6lpm nasal prongs. 02 sats 90-92%. Non productive slightly congested cough. Solumedrol given. No further changes made.\nContinue with nebs Q3hr and wean frequency as tolerated. Home Bipap(Preset settings Ipap 22, Epap 10 with 5-6lpm 02).\n" }, { "category": "Nursing/other", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 1569821, "text": "Respiratory Care\n\n Pt given alb/atr Q4 hours B/S dim with scatt rhonchi. BiPaP changed to NIMV U/A to deliver enough 02 via home unit. Placed on home settings but IPAP decreased due to vt's of 3 liters ending up on .40 and tolerated well with sats of 93% No BiPaP since this am pt denies any discomfort. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-09 00:00:00.000", "description": "Report", "row_id": 1569848, "text": "PROGRESS NOTE 7P-7A\nEVENTS: PT. REMAINED STABLE THROUGHOUT NIGHT. LEVOPHED GTT TTITRATED THROUGHOUT SHIFT TO MAINTAIN MAP GREATER THAN 60. PT. STARTED ON T-FEEDS AND FREE H20 FLUSHES VIA OGT. ALSO STARTED ON NS AT 100CC/HR.\n\nNEURO: PT. SEDATED ON 3MG/HR OF VERSED AND 25MCG/KG OF FENTANYL. SPONTANEOUS/NONPURPOSEFUL MOVEMENT NOTED. PT. RESPONDS TO VERBAL STIMULI AND FOLLOWS COMMANDS APPROPRIATELY. PUPILS EQUAL AND REACTIVE. NO PAIN ISSUES AT THIS TIME.\n\nRESP: PT. REMAINS INTUBATED. VENTILATOR SETTINGS: AC - 550X24/50/12. BREATH SOUNDS COARSE BILAT. DIMINISHED IN BASES. THICK TAN/FOUL SMELLING SECRETIONS WITH SUCTIONING. + MRSA IN SPUTUM. AM CXR RESULTS PENDING\n\nCVS: PT. HAS FLIPPED FROM A-FLUTTER TO NSR THROUGHOUT SHIFT. SBP WNL. MAP HAS STAYED ABOVE 60 WITH LEVOPHED GTT TITRATED TO EFFECT. PT. CURRENTLY AT 0.16MCG/KG. PT. WITH 3+ PITTING EDEMA THROUGHOUT TRUNK AND EXTREMITIES. + PULSES. TMAX 98.9 AXILLARY. R RADIAL A-LINE PATENT WITH SHARP WAVEFORM\n\nGI: OGT PLACED BY MDS AND PLACEMENT CONFIRMED WITH ABD. X-RAY. PT. STARTED ON NEPRO AT 10CC/HR. (TO BE INCREASED 10CC Q6H) PT. CURRENTLY AT 20CC/HR. PT. APPEARS TO BE TOLERATING WELL. ABD. OBESE. BS HYPOACTIVE. NO BM THIS SHIFT.\n\nGU: FOLEY WITH GOOD UO. APPROX 80-200CC/HR. CLEAR YELLOW URINE. URINE SPECIMIN SENT TO LAB FOR DIPSTICK.\n\nSKIN: INTACT\n\nACCESS: L IJ TL\n 2 18G PERIPHERAL IVS IN L ARM\n\nID: PT. REMAINS ON FLAGYL, VANCO AND LEVAQUIN\n\nENDO: PTS BLOOD SUGARS HAVE REMAINED IN MID 200S THROUGHOUT SHIFT. CONTINUE TO MONITOR Q4H.\n\nPLAN: CONTINUE WITH CURRENT PLAN OF CARE. MONITOR HEMODYNAMIC/RESPIRATORY STATUS CLOSELY. OFFER SUPPORT TO PT. AND HIS WIFE. ATTEMPT TO WEAN FROM LEVO GTT AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-09 00:00:00.000", "description": "Report", "row_id": 1569849, "text": "Addendum to 7p-7a progress note\nPt. had episode of hypertension (280's/130's) with 3-4 beat runs of V-tach turning into ventricular bigeminy then into NSR with frequent PACs. EKG and CXR obtained. MDs aware. Pt. cognitive throughout episode.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-09 00:00:00.000", "description": "Report", "row_id": 1569850, "text": "NPN 0700-1900\nNeuro; Pt. intubated and sedated on Versed 4 mg/hr and Fentanyl 25mcg/hr. Pt. responds to voice by opening eyes and body movements. Pupils 3 mm equal round and reactive. Able to do movement on command.\n\nResp: Pt. intubated on A/C 550x22 Peep 10 and 50% Fio2. Tolerated decrease in Peep and RR well. Last ABG at 1600 pH 7.41, PaCO2 54, PaO2 75 and HCO3 35. O2 sat 89-92% today. Pt. suctioned frequently for thick yellow secretions. Pt. has MRSA+ sputum. Plan to decrease vent settings as Pt. tolerates.\n\nCV: Pt. had a episode of Ventricular bigeminy at 0600 with increase in BP than decrease in BP requiering increase of levophed to 0.26 mcg/kg/hr. Pt. converted to NSR. One episde of tachycardia with rate of 140's noted that lasted for about 30-60 sec after which Pt. converted to NSR. BP increased to 180/60's at that point as well and slowley decrease to 140/60's. Levophed gtt titrated down to 0.06 mcg/kr/hr and ABP 120-130 systolic. MAP 65-75. Cont. to titrate levophed down to off. HR 70-90 NSR at this time. Pt has + pitting peripheral edema as well as generalized edeam. Upper ext. elevated to decrease edema. L IJ TLC intact dsg. changed today. R radial A-line intact with sharp waveform. 2 PIVs intact and WNL. K 3.7 this AM repleated with 40 Meq of IV KCL and repeat K 4.1 at 1500. CVP 15.\n\nGI: OGT reinserted and placement confirmed by ascultation and chest Xray. Nepro tube feeding restarted at 1300 at 10cc/hr and tolerating well will increase tube feeding at 1900. Pt. also started on free H2O boluses 400cc q 6 hr. Abd. distended obese and soft. No documented BM since adm. Pt. recieved Lactulase x1 today and started on ducolax PO and Colace TID. No BM at this time. Stool for C-diff to be colected when BM. Insulin sliding scale changed to to Insulin gtt @ 2 units/hr. SInce than Insulin gtt titrated up to 3 units/hr. See carevue for further rate changes.\n\nGU: Foley cath in palce and draining adequate amounts of clear yellow urine. BUN 102 creat 1.9 this afternoon. Fluid balance +2L for 24 hr and -8.5L for LOS. Lasix on hold for now until even I/O.\n\nID: positive for MRSA in sputum currently on Vanco IV and PO Flagyl and Levaquin. WBC 19.3 increased from . Low grade temp 99.9 today.\n\nSocial: Son in to visit today and Pt.'s wife and daughter in this afternoon. Pt.'s wife and daughter spoke with Dr. and updated on Pt.'s condition. Cont. to support Pt. and family. pt. remains a full code at this time.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-09 00:00:00.000", "description": "Report", "row_id": 1569851, "text": "Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. RR weaned from 24-22 today and peep decreased from . Pt initially had autopeep of 2 above set peep but essentially 0 now that rate has been decreased. Pt cont to receive Albuterol and Atrovent MDI's q vent check. Sxn for thick tan yellow-tan secretions. ETT pulled back 2cm per AM CXR. Plan is to follow ABG's and wean vent as pt tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-23 00:00:00.000", "description": "Report", "row_id": 1569905, "text": "Patient is a slow wean;trached and Peged yesterday evening. Has cuff leak which @ present time is less prominent. He's switched from A/C to PSV with good tolerence except when congested. Plan is to keep patient on PSV over night. he's being treated with metered dose inhalers albuterol/atrovent. patient is periodically suctioned for moderate to small amount of thick white sputum.ABg compensated with Pao2 64mmhg, full code will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-24 00:00:00.000", "description": "Report", "row_id": 1569906, "text": "Nursing Progress Note 1900-0700\n*Full Code\n\n*Allergies: NKDA\n\n*Access: RR A-Line, L sub.cl. multi-lumen\n\n*Precautions: MRSA\n\nIn Brief: Pt presented to EW w/ COPD exacerbation, SAT's in upper 70's on 6L NC (85% on 5L @ home \"a few weeks ago\") Pt stated he had thick yellow sputum for about a week. Tx'd to ICU for eval. Hx of Asthma, CHF, COPD and Diabetes. Currently attempting to wean off ventilation.\n\nNeuro: Pt mildly sedated. Aroused to speech and stimulation. Occasionally follows commands. PEARL @ 4mm brisk accommodation to light. Pt moves all extremities spontaneously, but lower more than upper.\n\nCardiac: NSR w/ occasional PVC's. HR 92-97, SBP 139-192, MAP 74-113.\nLevo remains off. MD's stated that MAP in the 50's will be tolerated for this patient. Pos. pedal pulses via doppler.\n\nResp: Trach wnl w/ clotting and minimal bleeding. Trach care done. Pt on CPAP+PS until 0230 when pt had an episode with HR >100, SBP >190, RR > 30, visibly had difficulty breathing. Respiratory and MD's notified and decided to put him back on CMV (vent settings 40/550/8/14) to allow him to rest. Requires frequent oral and trach sxn (thick, white sputum). RR 13-22. LS clear bilaterally uppper lobes, diminished bilaterally lower lobes. ABG's 7.38/60/67.\n\nGI/GU: Obese w/ pos. bowel sounds, no stool this shift. Colace and Bisacodyl held. TF () titrating up 10ml Q6H w/ goal of 40ml/hr. Set @ 30ml/hr @ 0400. Next increase @ 1000. BS 105-122 remaining in normal range all shift on 2U/hr insulin gtt. Lasix 40mg iv x 1 @ 2200. Pt continues to have +4 edema bilaterally upper and lower extremities and scrotum. Arms weeping copious yellow fluid. Left hand w/ abrasion on knuckle in DSD. Unable to weigh this shift as the bed scale is inaccurate.\n\nID: Temp. 97.7-100.5 trending up. Notify MD's if trend continues.\n\nPsycosocial: Supportive common law wife, called to check on his status. Son visited in the evening. Informed him of the start of attempting to wean the vent settings. Son stated that the family is happy w/ the care his father is receiving here.\n\nDispo: Full Code. Continue to monitor resp. status. Follow up w/ MD's regarding further attempts at CPAP+PS. Continue to monitor BS and titrate insulin per protocol. Increase TF per orders until goal of 40ml/hr. Continue to monitor I&O.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-24 00:00:00.000", "description": "Report", "row_id": 1569907, "text": "RESP CARE: pt remains trached with 7.0 Portex which has lg. positional cuff leak. Takes 12cc air to seal. IP notified of high cuff pressures./Pt was on PS 15/8/.40 until 0230 when pt became tachypneic with increased HR,drop in Vts. Placed back on AC to rest until rounds in am. SEE CAREVUE. Lungs coarse. sxd mod amts thick sputum from trach and oropharynx. MDIs given with good effect. PLAN: Have IP assess airway.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-13 00:00:00.000", "description": "Report", "row_id": 1569866, "text": "M/SICU NPN FOR 7A-7P: FULL CODE CONTACT FOR MRSA (SPUTUM)\n\nEVENTS: ABD CT SCAN W/O IV CONTRAST TODAY. UNABLE TO WEAN LEVAPHED GTT OFF.\n\nNEURO: SEDATED ON FENTANYL (25MCG/HR) AND VERSED (3MG/HR) GTTS. PERLA. RESPONDING TO PAINFUL STIMULI AND OPENS EYES W/ TURNING/REPOSITIONING.\n\nPULM: NO VENT CHANGES TODAY. REMAINS ON A/C X 20, TV 550, 50% FIO2, PEEP 10. BRIEF PERIODS OF OVERBREATHING. SUCTIONED INTERMITTENTLY FOR THICK YELLOW SECRETIONS. SPUTUM CX SENT. NO ABG DONE. ADEQUATE O2 SATS. NOTED.\n\nCV: AFIB-A.FLUTTER W/ HR 90-100'S. BP 99/42 - 125/45 W/ MAP'S 56-74. T. MAX 101.2. PAN. CX'D TODAY. REMAINS ON LEVAPHED GTT AT 0.2MCG/KG/MIN. ATTEMPTED SEVERAL TIMES TO WEAN GTT DOWN UNSUCESSFULLY. CONTS. W/ GENERLIZED UPPER/LOWER EXT. PITTING EDEMA. IV ACCESS IS VIA LEFT SVC TLC. HAS R RAD A LINE W/ GOOD WAVEFORM. CVP 16-18.\n\nGI/GU: ABD IS OBESE, SOFT, NT,ND. NO BM AT PRESENT. CT PREP OF BARIUM SULFATE SUSPENSION (2 BOTTLES) GIVEN. + HYPOACTIVE BS NOTED. 3/4 STRENGTH NEPHRO AT 50CC/HR VIA OGT. MIN. RESIDUALS. FOLEY IN PLACE OLIGURIA TO 15-32CC/HR.\n\nSKIN: GROSS AMOUNT OF + PITTING BODY EDEMA.\n\nENDO: INSULIN GTT CURRENTLY AT 5 UNITS/HR. CHECKING BG Q 2HRS.\n\nPLAN: CONT. W/ CURRENT PLAN OF CARE. ATTEMPT TO WEAN LEVAPHED GTT AT TOLERATED. UPDATE FAMILY AS NEEDED. MONITOR PER PROTOCOL. REPLETE ELECTROLYTES AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-27 00:00:00.000", "description": "Report", "row_id": 1569921, "text": "resp care\npt remains on spont mode, psv at 18, decreased to 14..tolerated for approx 3 hrs. then became tachypneic, failing to trigger the vent despite sxning, mdi's. resolved with increase in support. sxning thick white to yellow sputum. mdi's given q4h. c/w slow wean, cuff pressures remain high.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-27 00:00:00.000", "description": "Report", "row_id": 1569922, "text": "resp care addendum,\nabg reveals borderline oxygenation, will addresss with team need for increased fio2.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-28 00:00:00.000", "description": "Report", "row_id": 1569923, "text": "Resp Care,\nPt. remained on IPS 18 overnoc until 430 am, then changed to A/C. Pt. RR increased thruout noc to high 30's, VT decreased to 300's. Suctioned for thick yellow sputum and a large amount of oral secretions. Pt. did not sleep until placed on A/C. Plan rrest on A/C remainder of noc, then place back on IPS 18 in am. RSBI attempted, but unobtainable due to high RR. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-28 00:00:00.000", "description": "Report", "row_id": 1569924, "text": "NPN 1900-0700\nNeuro: Lethargic, eyes open in bed all night long, follows commands, wrist restraints intact bilat for safety.\n\nResp: Lungs dimished bilat.,Sx'd moderate amts of white thick secretions per ETT, sx'd copious amts of thin clear secretions per mouth. RR in 30's most of night on CPAP, ABG 7.37/66/61/60, switched to AC 40%/550/Peep 8/RR 14-17 with O2 sats 93-99%.\n\nCV: HR 67-98 NSR, no ectopy, BP's 121-168/46-78, A-line positional, correlating pressures with NBP. Given 60mg lasix IV to attempt to diurese pt -1L per Resident, lasix with little effect, Intern notified no new orders. T max 98.4.\n\nEndo: FBS 144-154, tx per SSI and standing dose.\n\nGI: Abd obese and distended, bs diminished, no bm. at 40cc/hr.\n\nGU: Foley cath intact draining clear yellow urine in adequate amts.\n\nSkin: Occasional moist d/t weeping of arms, skin intact.\n\nPlan: Continue to monitor VS, wean vent settings as tolerated. Send stool for c-diff when available.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-16 00:00:00.000", "description": "Report", "row_id": 1569875, "text": "NPN 1900-0700\n\nNEURO:INCREASED FENTYNAL TO 50MCG /HR AS PT WAS OVERBREATHING AND NON COMPLIANT W/ VENT. RR WAS LABORED , AGONAL AND RHYTHMIC.INCREASE IN RESOLVED IRREG BREATHING PATTERN.VERSED REMAINS UNCHANGED @ .5 MG/HR PT RESPONDS TO PAIN W/ GRIMACE ,POS COUGH AND GAG.\n\nRESP: NO VENT CHANGES .CONT ON A/C 24X550/40%/10 AM ABG 7.33/55.80.\nCOPIOUS AMTS OF ETT AND ORAL SECRETIONS. LUNGS COARSE THROUGHOUT.?? NEED BRONCH. ROTATED ETT AFTER FINDING BLOODY DRAINAGE AT CORNER OF MOUTH.\n\nC/V: AFIB/FLUTTER RARE PVC'S , LEVOPHED NOW @ .O8 MCG/KG /MIN.\n\nF/E/N: LASIX GTT W/ POOR RESULTS , ONE DOSE OF DIURIL ADDED W/ MIN EFFECT. GOAL WAS UO @ 100CC HR.MAX UO WAS 50CC/HR. PT IS IN ATN WHICH WILL PROBABLY RESOLVE ON IT'S OWN. BUN AND CREAT CONT TO CLIMB TO 113/3.3. INSULIN GTT TITRATED TO FSBS.TF CONT @ GOAL OF 5OCC/HR. NO STOOL OVERNOC.\n\nPLAN: CONT TO WEAN LEVO, LASIX FOR DIURESSES VS SELF LIMITING ATN, FOR VENT COMPLIANCE, CONT INSULIN GTT, FOLLOW AND REPLETE LYTES PRN, CONT AB TX. EMOTIONAL SUPPORT FOR FAMILY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-16 00:00:00.000", "description": "Report", "row_id": 1569876, "text": "Respiratory Care\nRemains intubated and ventilated on a/c 550 x 24 +10 40%. At times breathing in high 30s, very dysynchronous with the vent increasing airway pressures> 50. Currently, more sedated, appears comfortable with few breaths above the vent, airway pressures in low 30 Suctioned overnight for copious amounts of thick tan sputum, req. approx. q1 suction. ?Bronch might be of benefit. ABGS with slight resp acidosis, good oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-16 00:00:00.000", "description": "Report", "row_id": 1569877, "text": "Nursing 0700-1900\nEvents; CONTINUED TO DROP PRESSURE AS LEVO WAS DECREASED and during adm of lasix and chlorothiazide. Increased levo to 0.95mcg/kg/min to maintain MAP>60\n\nNeuro: PEARLA @3mm and brisk. Remains on 50 mcg/min of Fentynal; 0.5 mg/hr Midaz; 0.95 mcg/kg/min Levo to maintain MAP of >60. Withdraws to pain; Gag and cough reflex are positive.\n\nCV: Afib/flutter with rare PVC'S. BP: 81/49-132/72; CVP: 19-21\nT: 97.8-99.5. LEVO INCREASED TO 0.95MCG.KG.MIN TO MAINTAIN MAP>60\n+ pedal pulses by doppler bilaterally.\n\nResp: PEEP changed to 10; others remaind same FiO2=40%,TV=550 and Resp=24. Lungs bilaterall7 clear, diminished at both bases. Suctioned\nPRN which was much less than yesterday.\n\nGI/GU: TF remains @50cc/hr, which is goal. Minimial residuals, Hypoactive bowel sounds. Lasix 80 mg IV push and Lasix drip @ 2mg/hr initiated due to decreased output/ Urine was initially amber/cloudy and after Lasix is yellow and clear with output increasing.\n\nSkin: pitting edema . Arms leaking interstitial fluid-arms are wrapped in pads and changed q hr. Scrotal area edematous.\n\nSocial: Son and wife called this AM. Son spoke to MD a family meeting to discuss Trach and dialysis plans. I spoke to wife and informed her to speak with her son and make arrangements with him to come in for meeting.\n\nPlan: Attempt to wean Levo. as tolerated\nWean vent as tolerated\nContinue to monitoe Temp spikes\n??Trach and Dialysis line placement\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-16 00:00:00.000", "description": "Report", "row_id": 1569878, "text": "Pt continues on previous vent settings. BS occ rhonchi; no change with MDI's. PEEP remains at 10 - no ABG's. Sx'd for mod amt thick yellow secretions.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-04 00:00:00.000", "description": "Report", "row_id": 1569827, "text": "Resp Care\n\nPt currently on 60% hi-flow setup with spo2 in the mid to low 90s. Bronchodilators given Q4 via HHN tol well with stable HR and RR t/o Tx. BS dim with inspiratory crackles at the bases. Slight improvement in aeration noted post bronchodiltor therapy. Home care company in to see pt regarding seal on home bipap unit and was able to replace old unit with new mask. WIll cont with tx and wean FiO2 as tol.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-24 00:00:00.000", "description": "Report", "row_id": 1569908, "text": "Resp Care\n\nPt's mode on ventilation changed to CPAP/PSV after being placed on A/C for 5 hrs over night. ABG stabe at 7.43/51/79/35. MV in the 10-11L range with respiratory rates in the teens and low 20's. TV's have been in the high 500's. BS are diminshed with scatter fine rhonchi and suctioning thick yellow sputum in small amts.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-24 00:00:00.000", "description": "Report", "row_id": 1569909, "text": "MICU/SICU NPN HD #23\nS/O:\n\nNeuro: pt remains somnulent days after last sedating medications, eye open to voice, following simple commands, attempting to speak, denies pain, MAE\n\nPulm: trached on , currently on PSV 18/8/0.4, last ABG 7.43/51/79, SpO2 93-100%, LS clear upper lobes and diminshed at bases, frequent oral suctioning for moderate amts saliva, suctioned q3h for small amts frothy white/tan sputum\n\nCV: please see flowsheet for data, VSS\n\nInteg: pt is anasarcic, old venipuncture sites are weeping serous fluid, left hand has an old bulla which has broken and crusted over with blood and a bulla with dark fluid visible within\n\nGI/GU: abd is obese, softly distended, NT/ND, BS are present, tolerating at goal rate of 40cc/h without measuraable residual volumes, small liquid BM this AM, Foley patent for clear yellow urine in adequate amts\n\nAccess: left SC QLCL, right radial art line\n\nDisp: CM has initiated screening process for pulmonary , II started\n\nA:\n\naltered breathing r/t chronic lung disease\nhigh risk for infection r/t to invasive lines, indwelling cath, surgical incision\nimpaired skin integrity r/t fluid volume overload\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, activity progression, continue to wean resp support as tolerated, continue post acute care process\n" }, { "category": "Nursing/other", "chartdate": "2181-10-25 00:00:00.000", "description": "Report", "row_id": 1569910, "text": "Resp Care Note, Pt placed on A/C to rest overnight. Suctioned for mod amts thick white secretions. Temp 99.5 MDI'S given. Awake and alert.Will to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-28 00:00:00.000", "description": "Report", "row_id": 1569925, "text": "resp care\nremains trached/vented now in ac mode. trach with positional cuff leak. received pt on ac mode, placed back on psv at ps 20, tolerated for about two hours then had two episodes of tachypnea which only resolved with manual ventilation thus placed back on ac mode. sxning small amts yellow thick. mdi's given q4h and prn. c/w support, reattempt psv tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-31 00:00:00.000", "description": "Report", "row_id": 1569935, "text": "NPN 7pm to 7am\nNeuro: Afebrile, opens eyes to voice. Son visited in evening, mouthing words to son but incomprehensible. Follows commands to squeeze hands.\nResp: required less frequent suctioning tonight than last night but continues to have thick yellow secretions suctioned q 1-2hours. Remains vented via trache, no vent changes made O2 sats 92-94%. RR 16-21. Trache care done, w/small amt sang drainage around trache site, sutures intact.\nCV: 90-60 to 140/60, HR 80s SR. I/O +55cc, w/anasarca.\nGI: Tube feeds advanced q4hr as tolerated, minimal aspirates. ABD large soft, BS+, no BM this shift thus far.\nGU: foley patent, clr yellow urine.\nSkin: Left hand dressing removed. Blood blister over knuckle region intact and then what appears as black scab on posterior aspect of hand, scab cleansed and triple antibiotic ointment applied. Hand elevated on pillow to help w/edema. Dr. in to eval hand and agrees w/POC.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-31 00:00:00.000", "description": "Report", "row_id": 1569936, "text": "REsp Care Note\n\nPt remains on AC vent, 14 xs 550, + 8 , 40% O2 . There are still significant amts of thick yellow sputum, sx from # 7 trach tube. Plan to transfr pt to rehab later this week\n" }, { "category": "Nursing/other", "chartdate": "2181-10-04 00:00:00.000", "description": "Report", "row_id": 1569828, "text": "MICU NPN\nNEURO: ALERT AND ORIENTATED X3, PLEASANT AND COOPERATIVE.\n\nRESP: IN O2 VIA N/C AND FACE MASK, DESATS VERY QUICKLY IF FACE MASK IS OFF FOR ANY PERIOD OF TIME. PT. DID DESAT AS LOW AS 68%, ABG WAS DONE AT THAT TIME SEE CAREVUE FOR RESULTS, NO CHANGES WERE MADE TO PT'S O2 DELIVERY AND SAT CAME BACK UP TO LOW 90'S PT. VERY SOB EVEN AT REST. HOME CARE CO. THAT PT USES BROUGHT IN A NEW MASK FOR BIPAP MACHINE.\n\nCV: HR AND BP STABLE SEE CAREVUE FOR NUMBERS.\n\nGI: TAKING IN PO FOOD WELL, FOLLOWING DIET. NO BM TODAY.\n\nGU: FOLEY IN PLACE, URINARY OUTPUT GOOD SEE CAREVUE FOR NUMBERS.\n\nENDO: CONTINUES WITH INSULIN GTT, TITRATED ACCORDING TO HOURLY FINGER STICKS. ALSO CLINIC MD WAS IN TO SEE PT TODAY AND SUGGESTED THAT PT. TO START ON A INSULIN SLIDING SCALE AND HS GLARGINE.\n\nSOCIAL: WIFE IN VISITING AT BEDSIDE.\n\nPLAN: CONTINUE TO MONITOR RESP. STATUS, FOLLOW FS, TITRATE INSULIN GTT. AS NEEDED. START GLARGINE TONIGHT .\n" }, { "category": "Nursing/other", "chartdate": "2181-10-05 00:00:00.000", "description": "Report", "row_id": 1569829, "text": "NPN 1900-0700\nNeuro: Pt. alert and oriented x3. Pleasant and cooperative with care.\n\nCV: VSS, BP 130's-150's/40's-60's, HR 90's NSR with rare PVC. K 4.6 on . AM labs pending. Two PIV one with NS at KVO.\n\nResp: Pt. with advanced COPD at home at 5L NC. Pt. on 60% Hi flow O2 face mask. Pt. has episodes when he desats to 70's and is very SOB and laboring to breath. LS dim. with exp. wheez. Pt. recieved neb treatments and recovered within 15-30 min. Pt. placed on home BIPAP for shoft time but O2 sat 88-89%. O2 sat mid 90's on 60% face mask. No ABG dran this shift. Episodes of SOB and labored breathing do not seem to be precipitated by any activity. Pt. cont. on IV solumedrol.\n\nGI: abd. large obese, BS +. Pt. has good appetite and tolerating diet well. Pt. needs to remain on O2 mask while eating. Insulin gtt off at 2300 on as ordered. BS aat 2400 147. Pt. started on RISS and lantus insuline at bedtime. BS at 0300 247 Pt. recieved 4 units regular insulin. WIll cont. to check BS q@ hr and cover with insukin as needed. No BM this shift.\n\nGU; Foley cath in place and draining adequate amounts of clear yellow urine. Pt. is on IV lasix .BUN 76, creat 1.9. Fluid balance -.64L for 24 hr and -7.4L for LOS.\n\nSocial: Pt.'s wife and daughter in to visit and updated by MD on Pt's progress. Pt. is a full code. Cont. to update Pt. and family on further plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-05 00:00:00.000", "description": "Report", "row_id": 1569830, "text": "Respiratory: Pt rec'd on HF face mask with 02 sats 92-93%. Bs are diminished bilaterally. HHN tx's given Q4 hrs Alb/Atr with noticable improvement. NPC Pt placed on own cpap machine with full face mask. Pt began to desat to low 80's. Pt retured to HF 02 with immediate improvement. Pt has episodes of ^ wob which takes 20-30 minutes to recover. Will continue on present settings.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-19 00:00:00.000", "description": "Report", "row_id": 1569888, "text": "Respiratory Therapy\n\nPt remains orally intubated on PSV, currently +18PSV/+8PEEP w/ acceptable ABG. BLBS diminished at bases, coarse anterior upper lobes. Suctioned for moderate amounts of thick whitish/light yellow sputum. Positional cuff leak noted, cuff pressure = 23cm H2O. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2181-10-20 00:00:00.000", "description": "Report", "row_id": 1569889, "text": "Respiratory Care Note:\n Patient remains on PSV of 18/8, 40% and abg of 7.36/54/74/32/+2. RR=24-32. Patient appears relatively comfortable. BS diminished t/o. Last CXR avail with bilat LL opacities, improving pulmonary edema, cardiomyopathy and small bilat effusions. Failed RSBI attempt this am. Plan to wean on PSV as tolerated. See Carevue flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-20 00:00:00.000", "description": "Report", "row_id": 1569890, "text": "NPN-MICU\nMr. to make slow progress.\nResp: pt has on PSV of 18/8, min changes noted in ABG but pt looks to be working harder as he wakes up more.His RR is up to 24-30, TV 400-450 and O2 sats 90-94%. His O2 sat is less (90% with his left side down). He has min white secretions and he to diures well on his Lasix drip. CXR pnd. He with his inhalers.\nCV:pt has to keep BP 110-140/60-70's on sm amt of Levophed (.06mcg/kg/mn), HR in the 90's AF.he with intermittent PVC's, K+ pnd.\nGU: He to diures with lasix drip, u/o about 120cc/hr. His I&O to be neg and he is less puffy though still edamatous with weeping skin tears.\nGI:pt tol TF at goal rate fo 40cc/hr, no asp noted. He is passing liq stool, OB-. hct pnd. His BS have been labile but now at 4 Units of insulin/hr\nNeuro:pt to open eyes to name but no real interaction. He will move his feet & hands when touched but not always to commands. He has been off meds for >24hrs now.\nID: pt with low grade fever, on x3 IVAB\nSkin:left hand very edamatous, +pulses sm amt of serous drainage, site has some blk spots but no further changes notedpt ooze from skin tear sites.\nA/P:Will with diuresis and follow labs,lytes and progress with CXR improvement, slow wean as tolerates and pulm toilet a sneeded\n Will monitor for pt tolerance to TF, cover BS as ordered, note hct\n to keep MAP >70 on Levo\n IVAB and follow fever curve\n Asses for mental status improvements as he wakes up more\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-20 00:00:00.000", "description": "Report", "row_id": 1569891, "text": "Resp Care\n\nPt's mode of ventilation was changed today to A/C 550/22. Pt had lighten and had developed auto peep on PSV. Small amt of given and pip's decreased to 35 from 45. BS are diminished and with scattered fine rhonchi. Suctioning thick yellow plug like sputum. ABG after change in mode 7.35/60/78/35. Spo2 had been between 92-93%\n" }, { "category": "Nursing/other", "chartdate": "2181-10-20 00:00:00.000", "description": "Report", "row_id": 1569892, "text": "Mr admitted with hypoxia PNA COPD continues on ventilation since possible trachea and peg placement next week\nResp pt with labored breathing this AM RR up to 34 O2 90-88% Resp in to suction and adjust ventilator settings Ativan also given with good results pt resp rate much improved as well as O2 sats Pt seems to tolerate lying on right side better with an increase in O2 sats while on that side Suction with yanker for white secretions throughout day and 1X ET beside resp suction\n\nCV Pt has continued to keep B/P down on 0.4mcg levophen Has had flucuations throughout the day with B/P 100 /54 170/90's reamins currently stable @ 137/56 HR running tachy in 90's. MAp to kept between 65-70\n\nGU diuresing with Lasix continuing @10cc/hr weight @130.8 kg down from yesterday 133.7 Continues to have 3+ edema in upper and lower extremities with serous drainage in both arms\nDrainage amt appears to be reduced from yesterday.\n\nGI Pt continues on TF @ 40/hr with 5-10 cc of residual foley in place draining large amts of clear yellow urine His B/S low 100- 80-'s today with insulin drip running @ 3.5\n\nNeuro pt able to respond to name and also able to wiggle toes when asked to responded to partner when spoken to lifted arm appeared and tried to speak with mouth movement.\n\nSKIN Left hand very edematous with serous drainage dressing remained dry and intact through shift Right arm also edematous with drainage did move right arm up several times Buttock with 2 small reddened are skin barrier applied but continue to monitor Bilateral heels with some reddness barrier cream applied\n\nContinue to monitor improvement in mental status changes\nContinue to montior B/P and O2% RR\nWean Levaphed gtt as tolerated to keep MAP > 65.\n. q2hr fingersticks. Goal keep BG 80-120.\nLabs sent at 1600.\n\nAdditions by , RN:\n\nResp: Placed back on A/C x 22 TV 550, Fio2 .40%, PEEP 8. Suctioned q 2-3 hrs for thick yellow suction both orally and via ETT. O2 sats 92-96%. Latest ABG on current settings 7.35/60/70's.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-21 00:00:00.000", "description": "Report", "row_id": 1569893, "text": "Nursing Progress Note 1900-0700\n*Full Code\n\n*Allergies: NKDA\n\n*Access: RR A-Line, L Sub.Cl. Multi-lumen\n\n*Precautions: MRSA\n\nIn Brief: Pt. presented to EW w/ COPD exacerbation, SAT's in upper 70's on 6L NC (85% on 5L @ home \"a few weeks ago\") Pt stated he had thick yellow sputum for about a week. Tranfered to ICU for eval. Hx of Asthma, CHF, COPD, and Diabetes.\n\nNeuro: Pt mildly sedated but arousable to voice. Does not follow commands but does respond to touch and retracts from pain. PEARL @ 4mm brisk accomodation to light. pt moves all extremities spontaneously, but seems to move upper extremities more than lower, and moves right leg more than left,\n\nCardiac: NSR with occasional PVC's. HR 95-101, SBP 118-142 (occasional drop 80-90), MAP 73-105 (occasional drop 55-60). Treated drop in BP by increasing Levo. Responded appropriately, decreased levo to maintain MAP >65. Last Levo @ 0.050mcg/kg/min. Heparin 5000U SC given @ 00; PTT wnl according to 0400 labs.\n\nResp: Endotrach on ventilator (CMV) @ 40% O2. POX 95-98. Required occasional sxn to remove thick yellow sputum. Loosen w/ NS prior to sxn. RR 22-24. LS varied through out shift from bilateral upper lobe expiratory weezes to clear bilateral lung sounds to bilater expiratory wheezes. Respiratory also noted the changes. ABG 7.41/54/84.\n\nGI/GU: Obese w/ pos. BS, stool x3 (lg, med, med) dark brown and loose. Tube feeds ( 3/4 strength) @ 40ml/hr. Continuous insulin gtt. Started shift at 2U/hr. First BS @ 115 so increased according to protocol. Trend upward so increased gtt again to 3U/hr. Remains stable at this rate. KVO NS @ 10cc/hr. Foley in place 90-200cc/hour. On Lasix gtt @ 10 ml/hr. Diuresing well. +4 edema bilateral upper and lower extremities and scrotum. Arms weeping. Potassium replacement with KCL 40mEq x 1 Dose. Last lab 3.8. ARF w/ increase BUN and Creatinin. Weight 127.3kg\n\nID: Temp increased from 98.7 to 100.7. Last temp. 100.4. Started Acetazolamide 250mg IV to be given Q12H.\n\nPsychosocial: Supportive common law wife, called to check on his status. Does not wish for him to be in a long term care facility.\n\nDispo: Full Code. Continue Levo, Insulin, and Lasix gtt's. Monitor MAP and I & O and hourly BS. Adjust according to MD orders.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-08 00:00:00.000", "description": "Report", "row_id": 1569845, "text": "NPN 0700-1900\nNeuro: Pt. intubated and sedated on Versed 3 mg/hr and Fentanyl 25mcg/hr. Pt. arousable to voice able to open eyes and move hands and feet on command.\n\nResp: Pt. with a lot of thick yellow secretions and suctioned frequently. O2 sat 91-96%. Vent settings CMV 550x26 peep 12 and FiO2 50%. ABG at 1100 pH 7.46 PaCO2 51 PaO2 74. Pt. seems comfortable at this vent settings. MRSA pneumonia. No bronch today.\n\nCV: L IJ TLC and R redial A-line intact. Pt. in NSR this AM than converted rhythom to A-flutter with HR to 90-105 but ABP down to 70-80 systolic. Pt. was on Dopamine at 5 mcg/hr/hr. EKG obtained. ICU team made aware. Dopamine weaned off and Levophed started and currently at 0.12mcg/kg/hr to maintain MAP.60. HR 80-100's A-flutter. BP stable at this time. Electrolytes WNL. CVP 10 at 1200. Pt. also recieved 500cc NS fluid bolus with only slight increase in BP. Metoprolol and Lisinopril d/c'ed. Pt. has + pitting pedal edema.\n\nGI; Pt. NPO at this time. OGT will be inserted by medical student instead of NGT to minimize risk for sinusitis. Nutritional consult in place. Abd. large obese BS hypoactive. Glucose control good at this time BS at 0800 116 and 153 at noon. MD in to see Pt. and made recomendation. No BM this shift.\n\nGU: Foley cath in place and draining adequate amounts of clear yellow urine. Lasix stoped today. Fluid balance +.24L for 24 hr and -2 L for LOS. BUN 100 and creat 2.2.\n\nSocial: Pt.'s wife and daughter in to visit. updated on Pt.'s condition. Pt. is a full code. Cont. to support Pt. and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-08 00:00:00.000", "description": "Report", "row_id": 1569846, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. autopeep of this morning. Rate decreased from 28-26. Cont to receive Albuterol and atrovent MDI's, autopeep 3 this afternoon. Sxn for thick yellow secretions. Cont vent support, follow ABG's\n" }, { "category": "Nursing/other", "chartdate": "2181-10-08 00:00:00.000", "description": "Report", "row_id": 1569847, "text": "Addendum\nCV: Levophed gtt up to 0.14 mch/kg/hr at this time. BP 90-100 systolic with MAP at >60.\n\nGI: Nepro full strenght to be started when pump gets here. Stool for C-diff to be obtained when pt. has a bm.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-23 00:00:00.000", "description": "Report", "row_id": 1569901, "text": "Resp Care\nPt. trached with #7 Portex. However had episodes of desat's shortly after shift change. Found to have gross air leak from Trach. Cuff inflated in increments, with little effect. Currently cuff pressures equal to or exceeding 60cmH20, surgery aware. Leak still persistant however VT's,SPO2 etc. improved.\nabgs:unremarkable from prior labs.\nBs: rhonchi at times sxn'd q2-3 for copious amts. of thick tan.\nPlan: Pt. needs a larger trach, most likely will return to OR for a replacement sometime today.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-23 00:00:00.000", "description": "Report", "row_id": 1569902, "text": "Nursing Progress Note 1900-0700 .\nGI/GU: Obes w/ pos. bowel sounds, one lg. stool 0500 (brown, loose). Colace and Biscodyl were held. Continue to hold tube feeds, only meds via PEG. BS and urine started to drop, started D5 1/2NS @ 75cc/hr. BS and urine increased to wnl. Gave 25ml 50% Dextrose. No lasix at this time. +4 bilaterally upper and lower extremities and scrotum. Arms weeping copious yellow fluid. Left hand w/ abrasion on knuckles (cleansed w/NS, DSD, elevated hand). Weight 125.9kg.\n\nID: Temp stable most of shift, last temp 99.6.\n\nPsycosocial: Supportive common law wife, called to check on his status. Does not wish for him to be in a long term facility.\n\nDispo: Full Code. Continue Levo as needed (currently OFF, MAP > 85). Follow up w/ MD's regarding restarting TF. Continue to monitor FS, start insulin gtt per protocol. Continue to monitor I&O's.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-12 00:00:00.000", "description": "Report", "row_id": 1569860, "text": "Respiratory Care Note:\n patient remains orally intubated and on ventilatory support. Alarms tested and functioning properly and within normal limits. no changes made this shift to vent settings. for specific settings, please see carevue. SX'd for moderate amounts of yellow thick secretions, lavaged several times. BS diminished throughout. MDI's administered as ordered. Will continue to follow and wean when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-12 00:00:00.000", "description": "Report", "row_id": 1569861, "text": "NPN 2300-0700\n\nNEURO: ADEQUATELY SEDATED ON FENTYNAL 25 MCG/HR AND VERSED 2MG/HR, ATTEMPTS TO OPEN EYES ON COMMANDS, DOES NOT TRACK.\n\nRESP: CURRENTLY ON A/C 20X550/50%/10 W/ AM GAS OF 7.36/57/95.IMPROVED FROM EVENINGS.\n\nC/V: SR-ST NO ECTOPY, ABLE TO WEAN LEVOPHED DOWN TO 0.025 MCG/KG/HR.CVP 17-19 .CONT TO HAVE + 3 PITTING EDEMA OF EXTREMETIES AND SCROTOM.\n\nF/E/N: PT ,UO 50-80 CC/HR, AM LYTES PENDING.TOL @ 50CC/HR,INSULIN GTT TITRATED TO FSBS.BS FAIRLY STABLE IN 100'S-1TEENS. NO STOOL OVER NOC.\n\nPLAN; CONT TO WEAN LEVO , WEAN VENT AS TOL, FOLLOW AND REPLETE LYTES, CONT ATIBX\n" }, { "category": "Nursing/other", "chartdate": "2181-10-12 00:00:00.000", "description": "Report", "row_id": 1569862, "text": "RESP: BS'S CLEAR. ABG'S SHOWED PO2 OF 88. FIO2 DROPPED TO 40%. SATS DECREASED TO 88%., PLACED BACK ON 50%. REPEAT ABG'S SENT. SUCTIONED FOR MOD. AMTS OF THICK YELLOW SECRETIONS.\nGI: TOL. TF'INGS WELL. NO BM YET TODAY. BS'S PRESENT.\nRENAL: ADEQUATE U/O'S WHEN MAP'S OVER 65. CREAT 2.2. LASIX ON HOLD.\nNEURO: SEDATED ON FENT AND VERSED. MORE RESPONSIVE THIS AM.\nCV; PT. WAS IN NSR WITH OCCASS TO FREQ. PAC'S. THIS AFTERNOON DEVOLOPED AF-FLUTTER UP TO THE 120'S. BECAME HYPOTENSIVE TO 70'S. LEVOPHED HAS BEEN GRADUALLY INCREASED TO MAINTAIN A MAP OF >65. LOPRESSOR 3MG IVP GIVEN WITH HYPOTENSIVE EPISODE. NEED TO REVERT BACK TO NEO FOR BP CONTROL. CJVP 17-18. OVERALL EDEMA PERSISTS.\nID: FEBRILE-100.6AX. GIVEN TYLENOL WITH LITTLE EFFECT. VANCO LEVEL HIGH. NO DOSE TODAY. CONT. ON ANTIBIOTICS.\nENDOC: CONT. ON INSULIN GTT AT 4U/HR. BS'S CHECKED Q2HRS. LYTES SENT AT 17PM. URINE LYTES SENT EARLIER.\nSOCIAL: SONS AND WIFE AND DAUGHTER INTO VISIT FOR A SHORT TIME.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-04 00:00:00.000", "description": "Report", "row_id": 1569825, "text": "NPN 1900-0700\nNeuro: Pt. alert and orientedx3. Coooperative and calm. Able to communicate his needs.\n\nResp: Pt. with episode of resp. disters and desat to 84-87% on 60% cool neb face mask. Pt. states \"i can't catch my breath\". FiO2 increased to 100% and after a neb treatment O2 sat up to 90-96%. Pt. was unable to tolerate BiPAP because of hospital mask. Pt.'s own mask broken and needs new one ordered from his home BIPAP service.\nLS diminished with occ exp. wheez. Pt. on IV steorids, nebs and inhalers.\n\nCV: HR 60-70 NSR with no ectopy noted. BP ranging 140's/60's. Echo done on shows normal EF with dystolic disfunction. Pt. has + pitting edema to bil. lower ext. K 5.4 on . AM labs pending.\n\nGI: abd. obese and soft, BS+. Tolerating diet well. atempting to move bowels at this time. Pt. with Hx. of DM. BS in 400's on . Pt. started on Insulin gtt and is currently at 1unit/hr. Pt. was also started on D5 1/2NS at 50cc/hr to prevent hypoglacemia after 5 unit Insulin bolus IV. Will adjust D5 1/2NS infusion to maintain BS<200. BS since midnight 117-187. No BM this shift.\n\nGU: Foley cath in place and draining adequate amount to clear yellow urine. Fluid balance -.32L for 24 hr and -3.8L for LOS. Bun 78, creat 2.1. Cont. to monitor. Pt. on IV lasix .\n\nSocial: Pt. is a full code. No calls or visits from family since midnight. Will cont. to update Pt. and family on further plan of care.\n\nPlan: Titrate O2 to minimum requerments without episodes of desaturation.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-04 00:00:00.000", "description": "Report", "row_id": 1569826, "text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs Q4hr. Bs crackles at bases with expiratory wheezes bilaterally. Wheezes resolving over course of shift. RR 16-mid 20's.Pt. unable to use home Bipap due to full face mask not sealing. Rubber seal not tight to mask. Pt. attempted to use home Bipap with new foam mask but unable to tolerate mask/head strap. Also tried using mask ventilation but again uable to tolerate mask. Pt. waking up sob and desating to mid 80's. Resolved with brief increase in Fio2/Neb RX. Bs improved with bronchodilator therapy. Pt. receiving Solumedrol 125mg TID/Lasix 80mg via RN. No further changes made. Home Bipap settings Ipap 22, Epap 10, with 5lpm O2. Pt. uses home O2 5lpm when off Bipap. Currently on 70% cool mist with aerosol mask. 02 sats 92-93%.\nPlan: Call Home Care Company for new mask. Will have patient wife bring in old mask if possibe. Continue with nebs Q2-Q4hr.\nWean Fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-17 00:00:00.000", "description": "Report", "row_id": 1569881, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Currently on A/C ventilation, not overbreathing set RR of 24, maintaining Ve ~13L, PIP/Pplat = 37/24. BS w/ scattered rhonchi, suctioned for moderate amounts of thick tan secretions at beginning of shift, then white frothy secretions noted this afternoon. MDIs given as ordered. SpO2 remained >91%. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; ?trach placement soon...\n" }, { "category": "Nursing/other", "chartdate": "2181-10-18 00:00:00.000", "description": "Report", "row_id": 1569882, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings: A/C 550*24 40% with 8 peep.\nBreathsounds are coarse. Albuterol/atrovent given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-18 00:00:00.000", "description": "Report", "row_id": 1569883, "text": "1900-0730 Shift Report\n77 year old male, initially admitted to the icu with Hypoxia, Possible exacerbation of COPD, and probably pneumonia. Treated conservatively for three days with facial Bipap, went on to be intubated following aspiration. Has gone on to develop sepsis, renal failure and cardiac failure. MRSA +ve\n\nPMH - Asthma\n COPD (on 5l home oxygen)\n CHF\n DM\n Obesity\n\nResp - Remains fully ventilated on CMV 24x550 PEEP 8 FiO2 40%, no spontaneous breaths, SpO2 92-95%, 0700 ABG pH 7.33 PaCO2 56 PaO2 72, thick mucoid secretions, plugged off at 0300 required bagging (SpO2 down to 70%). Clear breath sound bilaterally to the upper zones, diminished at the bases. ETT retaped by RT 0500 24cm at the lips.\n\nCVS - Remains in AFIB HR 90-100, SBP 100-150 MAP 70-90 on 0.08mcg/kg/min Levophed (Aim MAP>70), Levophed reduced to 0.06mcg/kg/min at 0600 (well tolerated). CVP 30-40 (poor trace/unreliable). Febrile to 101.7, pan-cultured (2xBC 1xUrine), down to 98.7 with tylenol and cooling bath. Grossly edematous to extremities and scrotum, weeping ++ from upper limbs. Peripheral pulses present. CSL insitu overnight. Continues on Linezolid, Pipercillin and Metronidazole. HCT stable 29%, WCC down to 14.1\n\nRenal - Continue on Lasix infusion 10mg/hr maitaining urine output 100-200ml per hour. Not achieving a negative balance (however insensible losses not taken into account), BUN 119 Creatinine 3.4 ?CVVHD required.\n\nNeuro - Sedated on Fentanyl 50mcg/hour, Midazolam 0.5mg/hour. GCS 8 (E2/V1.0/M5), Pupils equal and reactive 3mm, Responds to voice, unable to follow commands, not making purposeful movements. In soft restraints overnight for patient safety, bed armed and side rails up.\n\nGI - Being tube feed on full strength going at goal rate of 40ml/hour, 4 hourly aspirates are minimal. Bowel sounds present. Bowels not open over night. Blood glucose raised slightly overnight to 164, insulin infusion increased to 4 units per hour as per protocol.\n\nSkin - Upper extremities weeping ++ serous fluid, pads changed multiple times overnight. Back and sacrum intact. Skin tear on left hand appears necrotic, redressed 0500 with adaptic and swabs.\n\nPartner was updated about his condition overnight.\n\nPlans - Wean from ventilation as able\n Discuss plans for trache with family\n Wean from levophed as able maintaining MAP > 70\n Requires renal review - ?CVVHD\n Review Lasix infusion\n Review skin tear and necrotic areas on left hand\n Discuss prognosis with family\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-23 00:00:00.000", "description": "Report", "row_id": 1569903, "text": "NSG 0700-1900\nEvents: changed Vent from CMV to CPAP+PS 18/8\n Maintained BP, MAP throughout day.\n\nNeuro: Responds to voice. Opens eyes and follows commands. Moves all extermities. PERLA @4mm with brisk accomodation. Sclera is white\n\nCV: NSR with occ. PVC's SBP: 119/51-169/62. Cap refill < 3sec. 3+ pitting pedal edema in both feet and hands. MAP maintained in 70's.\nFeet are 3+ edema, which is down from previous days of 4+.\n\n\nResp: Vent settings changed to CPAP+PS at 12:34, RR: 18-30 range. Noticed when he needed to be suctioned, his BP and MAP would start to climb. After respiratory did deep suctioning with added saline, he returned to a very quiet resting state and BP and MAP returned to today's baseline.. Suction mouth frequently for bloody and thick secretions.\n\nGI/GU: ++BS in all quads. ABD. is obese, but less than previous days.No BM this shift. , full strength, started at 1600@ 10ml/hr. Increase q6hrs of 10ml/hr until goal of 40ml/hr . is reached. Flush Q6hrs.\n\nSkin: Warm and dry except his seeping arms. Changed dressing on L. arm, R. hand is black in color. Continued to wrap arms in bed pads throughout day to absorb drainage, which remains yellow in color.\n\nPsychosocial: Supportative family..commom-law wife, daughter and into visit today. Continue to inform on progress and plans.\n\nPlan: Full Code. Continue CPAP+PS tonight. Monitor hemodynamic parameters. Monitoe I&O. Continue plan to D/C to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-23 00:00:00.000", "description": "Report", "row_id": 1569904, "text": "Addendum to NPN\nIn regards to above skin assessment pt is anasarcic, BUE are dressed with DSD for weeping old venipuncture sites, right hand has an eccymotic area purple in color and left hand has two blisters one open and crusted with dry blood measuring ~3cm in diameter and the other is ~3cm in length with old dark fluid visible within. The open blister was covered with triple abx and dressed with DSD.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-27 00:00:00.000", "description": "Report", "row_id": 1569918, "text": "Respiratory Care:\n\nPatient trached with 7.0 Portex. Cuff pressure 40cm H20 to seal trach. Physican aware of high pressures. Pt. weaned to Psv yesterday and continues to do well on Psv 18, Peep 8, Fio2 40%. Spont vols 600-700's with RR mid teens to low 20's. Bs clear and decreased bilaterally. Sx'd for sm-moderate amounts of thick white secretions. Albuterol/Atrovent MDI's given Q4hr. Abg's reveal compensated resp acidosis. No further changes made. Plan: Repeat RSBI. Slowly wean Psv as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-27 00:00:00.000", "description": "Report", "row_id": 1569919, "text": "NPN 1900-0700:\n\nOverall uneventful night.\n\nROS:\nNEURO: Remains off all ; restless at times, lethargic at other times, sleeping in naps. Denies pain, MAE, f/c, nods/shakes head, mouths words.\nRESP: Able to remain on PSV all night for the first time. Minimal secretions. LS CTA, sats mid-high 90's, RR 12-20.\nC-V: BP better controlled on higher dose of Lopressor, but could consider further increase. Lytes WNL last evening, pending this AM.\nID: Low-grade temp, WBC pending, off all abx.\nGI: Tolerating TF's at goal; belly benign, no stool.\nGU: Given 40mg IV Lasix X 2 with modest results. Overall still running positive, but all of intake is TF's and free water. BUN/creat to trend down.\nHEME: No active issues.\nSKIN: No new changes.\nENDO: Sugars in the mid-200's on increased NPH dose with SSRI.\nSOCIAL: One son visited, wife called for update.\nACCESS: MLC; a-line less positional than last night.\n\nA: very stable, ready for transfer to rehab.\n\nP: Continue PS wean as tolerated; OOB to chair daily; consider involving PT; adjust insulin dosage as needed for better control; check with nutrition to see if change in TF is in order given improvement in renal function; diurese as ordered; ? increase Lopressor further; transfer to rehab when appropriate bed is available.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-10-27 00:00:00.000", "description": "Report", "row_id": 1569920, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Oob to chair for several hours this pm. Ps decreased for several hours.\n\n Neuro: Opening eyes to verbal stimulus, appears to track at times, nodding head on occn. Remains restrained for pt safety. Moving all extrem. on bed as of this time. Temperature max. 99.2 oral.\n\n Respiratory: Lung sounds ae clear in upper fields, diminished in lower fields bilat. Ventilator settings unchanged, ps .40/18/8. Tv 550-700, rr 8-34. Suctioned every 2-3 hrs for thick white/yellow secretions in scant to small amts. O2 saturation on present ventilator settings 93-98% Abg to be drawn and sent.\n\n CV: Sinus rhythm with no ectopy noted, rate 58-88. Abp 120's to 160's systolic. A line site wnl, waveform sharp, can be difficult blood draw. Qaud lumen site wnl, remains clamped. Lopressor increased to 37.5 mg .\n\n Gi/gu: Abdomen obese with + bs. Tf at 40cc/hr goal. Nutrition to see for change in tf. No bm this shift. Foley catheter patent and draining clear yellow urine 40-120cc/hr. lasix 40mg iv at 1430 with fair effect.\n\n Endo: Riss in use along with nph fixed dose. No coverage required for 10 am dose, covered at 1600 with 2 units regular insulin for bs 175. Nph dose increased to 32 units .\n\n Id: Sensitivities pending, no abx as of this time.\n\n Social: Wife in to visit with pt this pm.\n\n Plan: Make 1 liter negative if possible. Send stool for c-diff when obtained. Awaiting pt consult.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-18 00:00:00.000", "description": "Report", "row_id": 1569884, "text": "Nursing note (0700-1900) 16:20\n\n\nNeuro.\n stopped this am, little improvement as yet in mental status, barely opens eyes to stimuli, no movement to limbs or response to commands. Appears to be comfortable at present.\n\nResp.\nRate dropped to 22, good SpO2 continues, adequate ABG. Pt now overbreathig vent to rate of 28bpm. Pt with moderate amounts of pluggy yellow secretions this am, now white/frothy. Pt has had consistant cuff leak despite repositioning of tube and further air to cuff.\n\nCVS.\nPt remains in A-Flutter/fib at rate of 80's-90's with occasional PVC's.\nBP 110's-150's/50's-60's. Map 60's-80's, Levo remains at 0.06mcg/kg/min, unable to wean at present. CVP 20-30.\n\nID.\nTemp remains in 99's, continues on multiple abx, awaiting fungal and micro culture data.\n\nGI/GU.\nPt remains on TF's at goal, +BS with 2x loose BM's this shift, guiac -ve. C-Diff sample needed when next stools.\nPt continues on Lasix gtt at 10mg/hr, UOP 70-200mls/hr, pt currently 500mls -ve, diuril given with little effect. renal and medical teams not in favour as yet of CVVHDF as yet.\n\nEndo.\nFSG 90-160, Insulin at 4-5 units/hr.\n\nSkin.\nPt with generalised +4 pitting edema, leaking serous fluid from upper extremeties. pt on daily weights, today down to 131.8Kg.\nTeam aware of area on Left hand, monitoring for present.\nPressure areas intact.\n\nSocial.\npt visited by wife, updated as to condition, stressed that trache was to enable further treatment and was not a \"cure\" as she had stated. Discussed further that resp status may not improve to previous levels.\n son's have arranged to visit at 1pm tomorrow for family meeting to discuss trach etc.\n\nPlan.\nWean vent as able.\nWean Levo to MAP >70mmHg.\nMonitor for fevers.\nFSG Q2hrs.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-18 00:00:00.000", "description": "Report", "row_id": 1569885, "text": "Respiratory Care Note\nPt received on AC as noted. IMV weaned to 22. BS are diminished bilaterally. Pt suctioned for moderate amts thick, white to yellow secretions. MDI's given with little improvement in BS. ETT retaped at 24cm at lip. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-19 00:00:00.000", "description": "Report", "row_id": 1569886, "text": "1900-0700 Shift Report\n77 year old male admitted to with hypoxia due to possible pneumonia/COPD exacerbation. Maintained on Bipap for three days, intubated due to aspiration and poor maintainance. Developed cardiac and renal failure.\n\nPMH - COPD requiring home oxygen and overnight bipap\n CHF\n Hypertension\n Diabetes\n\nResp - Fully ventilated on CMV 22x550 PEEP 8 FIO2 40%. SpO2 93-96%, no spontaneous respirations, 0300 ABG pH 7.40 PaCO2 50 PaO2 91. Breath sounds clear to the upper lobes, diminished at the bases. Thick mucous secretions on ETT suction.\n\nCVS - Remains in AFIB HR 80-100bpm. SBP 110-140 MAP 70-85 (Levophed down to 0.04mcg/kg/min Aim MAP >70). CVP unreliable, poor trace. Afebrile. Continues on linezolid, pipercillin, and metronidazole. Peripheral edema is decreasing to the lower limbs and scrotum. HCT 29% WCC down to 11\n\nRenal - Urine Output 100-250ml/hour with 10mg/hour laxis infusion. BUN/Creatinine remain elevated. Potassium 3.7 after 40mEq K repletion overnight.\n\nNeuro - Remains off all overnight. Although slightly more responsive GCS has failed to improve. opening eyes spontaneously, not fixing and following. Not obeying commands. Is making nonpurposeful movements in lower extremities. No signs of pain\n\nGI - tube feed continues at the goal rate of 40ml/hour, minimal residual volumes. BM stable on 5units of insulin hourly. Bowels open twice overnight, thick liquid, stool sample sent for c diff identification.\n\nSkin - Peripheral edema is reduced in lower extremities and scrotum. Continues to weep ++ serous fluid from upper extremities. Skin tear on left hand redressed with adaptic and swabs. Pressure areas intact, tolerating side lying.\n\nLines - Aline/Cline redressed this AM.\n\nSpoke to the son 1900, he is optimistic about the patients prognosis, RN affirmed that patient is still critically ill with three-organ failure. He will be present for the scheduled family meeting at 1pm . RN spoke to partner on the phone to update about condition, she will not be present at the family meeting but intends to visit. She spoke to the doctors , she remains unrealistic about the patients prognosis.\n\nPlan - Continue to wean ventilation as able\n Obtain consent for trache\n Continue to wean Levophed as able\n Renal review - ?CVVHD/?continue Lasix infusion\n Wean insulin as able\n Family meeting with doctors and two regarding prognosis, trache and expectations.\n" }, { "category": "Nursing/other", "chartdate": "2181-10-19 00:00:00.000", "description": "Report", "row_id": 1569887, "text": "1900-7am shift report\n77 year old man admitted on with hypoxia due to pneumonia and COPD exacerbation. Maintained on bipap for 3days. Intubated due aspiration and poor maintenance. Since admission has developed renal failure along with significant cardiac failure,\n PMH copd with oxygen at home and overnight bipap,\nCHF, HTN, Diabetes\n\nResp Fully ventilated on 40% fio2 cpap with Peep 8and ips of 18. ABG on thesse vent settings=7.37/53/86/32/3. Breath sounds are coarse in upper lobes diminished in bases bilaterally. White frothy sputum suction from oral cavity with yanker throughout day and ett sx'd for mod amts of thick yellow sptum. pt occasionally noted to have air leak to ett cuff which appears to be positional.\n\nCVS remains in A Fib 80-96 and MAP 60-70.aim is for map>70.;evophed gtt titrated as needed to maintain map > 70 and presently infusing at 0.063mcg/kg/min. sbp has ranged 105-140. pt afebrile today and Continues on linezolid, pipercillin and flagyl.team may d/c all antibiotics tomorrow.\n\nNEURO Remains off . Was able to respond to team request to \"wiggle toes\" several times. opening eyes occassionally but unable to follow any other commands. No sign of pain is noted.\n\nGI tube feed continues at goal rate of 40/ml per hr. 0 residual throughout shift and tube placement checked by auscultation. Fingersticks stable with insulin running at 1.0 units/hr. Patient had 2 large BM of loose thick stool and will hold lxative/ stool softeners at for now.hct stable at 29.7. abd obese and soft with pos bowel sounds on auscultation\n\nSKIN Peripheral edema in lower extremities and scrotum. Upper extremities continue to weep serous fluid bilaterally. Skin tear on left hand with dressing intact tolerating turning on side well\n\nLines r radial aline dressing intact. pt also has l subcalvian tl.\n\nFamily meeting with team held this afternoon. both and partner attended . Family still optimistic about patient prognosis. Team spoke with family about patien's condition being worse then previous admission in hospital and asked if they would want life support measures taken. pt's family members strongly feel that pt would want everything done to keep him alive. will most likely consult surgical team to evaluate for trach/peg placement early next week. will continue with present medical management. pt is a full code and will keep fmaily well informed on a daily basis and offer emotional support.\n\n\n" }, { "category": "Echo", "chartdate": "2181-10-03 00:00:00.000", "description": "Report", "row_id": 102132, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 292\nBSA (m2): 2.40 m2\nBP (mm Hg): 134/42\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 10:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient. No LV mass/thrombus. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Normal\nascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR. Prolonged (>250ms) transmitral E-wave\ndecel time. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 60-70%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nNo masses or thrombi are seen in the left ventricle. There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Trivial mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. The tricuspid valve leaflets are mildly\nthickened. There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890351, "text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Trach placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left\n subclavian catheter. s/p trach\n REASON FOR THIS EXAMINATION:\n Trach placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDIES: PORTABLE AP CHEST\n\n INDICATION: The patient with MRSA pneumonia, CHF, status post trach\n placement.\n\n COMPARISON: .\n\n AP portable compared to supine portable . Lower one-third fields\n not imaged. Severe emphysema with severe CHF is unchanged. There is\n cardiomegaly and the distal contours are stable. No pneumothorax identified.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890739, "text": " 6:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate, effusion\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left\n subclavian catheter. s/p trach\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD and CHF with MRSA pneumonia, to evaluate for infiltrate or\n effusion.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n Comparison done to the portable chest x-ray of .\n\n FINDINGS: There is persistent congestive heart failure.Superimposed infection\n in the left lower lobe cannot be excluded.The ET tube and the left subclavian\n catheter are in good position. Note that the lateral half of the left chest\n and the right costophrenic sulcus is not included in the film.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890201, "text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for development of pneumonia, pre-trach XR\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter. Unable to extubate. trach tomorrow.\n REASON FOR THIS EXAMINATION:\n Eval for development of pneumonia, pre-trach XR\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:30 A.M. ON \n\n HISTORY: COPD, CHF and pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Moderate-to-severe pulmonary edema has worsened accompanied by increasing\n moderate bilateral pleural effusion. The heart is mildly enlarged and\n mediastinal vessels remain engorged. Tracheostomy tube is in standard\n placement. Tip of left subclavian line projects over the junction of the\n brachiocephalic veins. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888489, "text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for progression of pneumonia\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated\n\n REASON FOR THIS EXAMINATION:\n please eval for progression of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n COMPARISON: .\n\n INDICATION: MRSA pneumonia.\n\n FINDINGS: Endotracheal tube and nasogastric tube remain in place as well as a\n left internal jugular vascular catheter, not significantly changed allowing\n for positional and technical differences between the studies. The current\n study is limited by exclusion of the extreme lung bases from the radiograph.\n With this limitation in mind, cardiac and mediastinal contours are stable.\n There has been apparent slight worsening of vascular engorgement and perihilar\n haziness. More confluent opacities persist in the lower lung zone regions as\n well as bilateral pleural effusions.\n\n IMPRESSION: Slight worsening of perihilar and basilar opacities, suggesting\n progressive pulmonary edema. Underlying pneumonia is not excluded given the\n provided clinical history.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889059, "text": " 3:01 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p advancing ET tube\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated s/p insertion of left\n subclavian catheter\n REASON FOR THIS EXAMINATION:\n s/p advancing ET tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CHF with MRSA pneumonia, intubation and CV line placement.\n\n Endotracheal tube is 7 cm above carina. NG tube is present but location of\n distal end cannot be determined on this underpenetrated film. Left subclavian\n CV line has tip overlying proximal SVC. No pneumothorax. There are bilateral\n mid and lower zone pulmonary opacities, unchanged since prior film of same\n date..\n\n" }, { "category": "Radiology", "chartdate": "2181-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889753, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrate\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter. Unable to extubate.\n REASON FOR THIS EXAMINATION:\n please eval infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA pneumonia with left subclavian catheter.\n\n CHEST X-RAY, PORTABLE AP: Endotracheal tube and left subclavian central\n venous catheter are unchanged in position. The cardiomediastinal silhouette\n is stable. Persistent pulmonary edema is present with underlying ephysematous\n changes of the lungs. More confluent parenchymal opacities in left lower lung\n may represent concomitant pneumonia. There is a small right pleural effusion.\n The left costophrenic angle is not included in the film.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889885, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter. Unable to extubate.\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, congestive heart failure, with MRSA pneumonia, intubated,\n left subclavian catheter, unable to extubate.\n\n CHEST X-RAY, PORTABLE AP: Comparison is made to prior study of one day\n earlier. There is an endotracheal tube, which is unchanged in position with\n tip immediately below the thoracic inlet. A left subclavian central venous\n line is present with tip at the left brachiocephalic vein/superior vena cava\n junction. The cardiomediastinal silhouette is unchanged.\n\n Visualization of the lungs is limited, as half of the right hemithorax is not\n included on the film. There are diffuse bilateral airspace opacities (likely\n alveolar edema), which is likely worsened from the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890161, "text": " 4:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate trach position\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter. s/p trach\n REASON FOR THIS EXAMINATION:\n evaluate trach position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n INDICATION: Status post trach placement, eval position.\n\n COMPARISON: .\n\n FINDINGS: An ET tube has been removed and a new tracheostomy identified. Tip\n 8 cm above the carina. Multifocal bilateral opacities are unchanged. There\n are likely some layering pleural effusions that are also unchanged. No\n pneumothoraces or pneumomediastinum. The left subclavian catheter tip\n projects over the small SVC.\n\n IMPRESSION: New tracheostomy in standard position. Persistent bilateral\n multifocal opacities and bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887998, "text": " 5:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? pneumothorax s/p thoracentesis\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with shortness of breath,pulmonary edema\n\n REASON FOR THIS EXAMINATION:\n ? pneumothorax s/p thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old male with shortness of breath and pulmonary edema.\n Question of pneumothorax, status post thoracentesis.\n\n COMPARISONS: Comparison is made to at 7:00 a.m.\n\n There is interval decrease in the left pleural effusion. There is no\n pneumothorax seen. There are bilateral small to moderate pleural effusions.\n The pulmonary vascularity is probably unchanged. It is difficult to exclude\n pneumonia and it is present on prior radiograph. Skeletal structures are\n unchanged.\n\n IMPRESSION:\n 1. Interval decrease of left pleural effusion. No definite pneumothorax seen.\n 2. Stable appearance of the pulmonary vascularity, likely representing mild\n pulmonary edema. Underlying pneumonia cannot be excluded.\n 3. Bilateral moderate pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887566, "text": " 5:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for improvement in vol overload\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with shortness of breath\n\n REASON FOR THIS EXAMINATION:\n eval for improvement in vol overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:29 A.M :\n\n HISTORY: Shortness of breath.\n\n IMPRESSION: AP chest compared to 5:30 p.m.:\n\n Heterogeneous opacification confined to the lower lungs, left greater than\n right, has progressed slightly reflecting worsening pulmonary edema,\n accompanied by at least a small if not moderate sized bilateral pleural\n effusions. Heart is mildly enlarged. Azygos and other mediastinal veins are\n significantly distended. Given the asymmetry of pulmonary consolidation,\n pneumonia, particularly in the left mid lung could be present.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887881, "text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval pneumonia\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with shortness of breath,pulmonary edema\n\n REASON FOR THIS EXAMINATION:\n please eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST :\n\n COMPARISON: \n\n INDICATION: Shortness of breath.\n\n Examination is technically limited due to exclusion of a significant portion\n of the right mid and lower lung region from the radiograph. Additionally, the\n patient is rotated and there is motion artifact. With these limitations in\n mind, there is stable cardiomegaly and persistent vascular engorgement. There\n has been apparent worsening of perihilar haziness with increasing confluent\n air space opacities in the perihilar regions extending to the lung bases. A\n moderate left pleural effusion also appears larger in the interval. A right\n pleural effusion cannot be fully assessed due to exclusion of part of the\n right lung from the radiograph.\n\n IMPRESSION:\n\n Technically limited radiograph demonstrating apparent worsening of pulmonary\n edema and left pleural effusion. It is difficult to exclude underlying\n pneumonia. Follow up radiographs suggested.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 888129, "text": " 4:36 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval L IJ placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF now s/p central line placement\n REASON FOR THIS EXAMINATION:\n eval L IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:49 A.M., .\n\n HISTORY: COPD and CHF. Central line placement.\n\n IMPRESSION: AP chest compared to earlier on at 3:00 a.m. and 3:39\n a.m.\n\n Tip of a left internal jugular line is at the junction with the left\n subclavian vein. ET tube is in standard placement and nasogastric tube passes\n below the diaphragm and out of view. Mild pulmonary edema and likely small\n bilateral pleural effusions are unchanged since . ET tube is in\n standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888111, "text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with shortness of breath,pulmonary edema, COPD flare\n\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:01 P.M. ON \n\n HISTORY: Shortness of breath. COPD flare.\n\n IMPRESSION: AP chest compared to at 6:38 p.m.\n\n Mild pulmonary edema and small bilateral pleural effusions are stable. Heart\n has increased slightly in size but is still only top normal in caliber.\n Mediastinal venous engorgement suggests volume overload. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888122, "text": " 1:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF now s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3 A.M. ON \n\n HISTORY: COPD and CHF. Check ET tube placement.\n\n IMPRESSION: AP chest compared to 11:01 p.m. on :\n\n New ET tube is in standard placement. Mild pulmonary edema and moderate-sized\n bilateral pleural effusions have worsened. Heart is mildly enlarged and the\n mediastinal vasculature is engorged. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891248, "text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF s/p MRSA PNA now s/p trach.\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:03 A.M. .\n\n HISTORY: COPD, CHF and MRSA pneumonia.\n\n IMPRESSION: AP chest compared to and 29.\n\n Mild-to-moderate pulmonary edema is unchanged generally. There is more\n opacification at the base of the right lung, which may represent new edema or\n early pneumonia but is more likely increased in small right pleural effusion.\n Moderate left pleural effusion is stable. The heart is normal sized and mild\n mediastinal vascular engorgement is stable. Medial aspect of the left lung\n base remains consolidated due to atelectasis or pneumonia. Tracheostomy tube\n in standard placement. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888125, "text": " 2:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ETT and OGT> please get left lung!\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF now s/p reposition of ETT and OGT placement.\n\n REASON FOR THIS EXAMINATION:\n eval ETT and OGT> please get left lung!\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 2:39 A.M .\n\n HISTORY: Check position of ET and OG tubes. Please get left lung.\n\n IMPRESSION: AP chest compared to 3:00 A.M. on and 11:01 p.m. on\n :\n\n The right hemithorax is excluded from the examination. ET tube is in standard\n placement and a nasogastric tube can be traced to the lower esophagus where\n the tip is indistinct due to limitations of portable radiographic technique in\n a patient of this size. Subsequent chest radiograph centered over the\n mediastinum shows no pneumothorax and persistence of moderate pulmonary edema\n and small to moderate bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887785, "text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evl for increased pulmonary edema\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with shortness of breath,pulmonary edema\n\n REASON FOR THIS EXAMINATION:\n please evl for increased pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:42 A.M. \n\n HISTORY: Shortness of breath and pulmonary edema.\n\n IMPRESSION: AP chest compared to and :\n\n Moderate pulmonary edema and small-to-moderate bilateral pleural effusions are\n unchanged. The heart is large. Basal consolidation cannot be excluded, but\n some of the more severe areas of opacification in the perihilar left lung have\n improved suggesting that this was due to asymmetric deposition of edema.\n Upper lobe configuration suggests emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888215, "text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for progression of infiltrate\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n please eval for progression of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:43 A.M :\n\n HISTORY: COPD and CHF.\n\n IMPRESSION: AP chest compared to and 6th:\n\n Heterogeneous opacification in the lungs could represent pneumonia but is also\n consistent with progressive moderately severe pulmonary edema in the setting\n of emphysema. Small right pleural effusion is larger and mediastinal vascular\n engorgement suggests elevated central venous pressure or volume. ET tube is\n in standard placement, nasogastric tube passes below the diaphragm and out of\n view. Course of a left central venous catheter does not follow normal left\n brachiocephalic vein. There may be persistent left-sided superior vena cava.\n Clinical correlation recommended to exclude the possibility of inadvertent\n arterial placement or, less likely, an extravascular location, which I doubt\n given the absence of mediastinal widening or left pleural effusion.\n\n Dr. was paged at the time of dictation to discuss these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890930, "text": " 5:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF s/p MRSA PNA now s/p trach. Continuing to try to\n diurese.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:37 A.M. \n\n HISTORY: COPD, CHF and MRSA pneumonia.\n\n IMPRESSION: AP chest compared to chest films since , most\n recently :\n\n Moderate-sized left pleural effusion has increased while small right pleural\n effusion and pulmonary edema have decreased. Left lower lobe is consistently\n consolidated due either to pneumonia or unresolved atelectasis. Tracheostomy\n tube in standard placement. Left subclavian line tip projects over the\n junction of the brachiocephalic veins. Heart size mildly enlarged.\n Mediastinum midline. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890885, "text": " 2:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF s/p MRSA PNA now s/p trach. Continuing to try to\n diurese.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 77-year-old with COPD status post pneumonia and\n tracheostomy.\n\n CHEST: Film is underpenetrated. There is evidence of vascular congestion\n consistent with persisting failure. Bilateral effusions are probably present.\n Left lower lobe infiltrate could also be present. Tracheostomy tube is\n identified.\n\n IMPRESSION: Underpenetrated film, failure still present.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 890996, "text": " 12:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Picc line postion, placed this am in rt arm\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF s/p MRSA PNA now s/p trach.\n\n REASON FOR THIS EXAMINATION:\n Picc line postion, placed this am in rt arm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n COMPARISON: Film performed at 6:37 a.m. the same day.\n\n Film centered on the right side of the chest is submitted. The left lateral\n aspect of the chest is not included. Compared to the prior study, a\n right-sided PICC line has been placed which is coiled in the right axilla.\n Findings were communicated to , and a message was left for Dr. \n at 3:15 p.m.\n\n Tip of the tracheostomy tube remains in good position, and the tip of the left\n subclavian line is at the junction of the innominate vein and SVC. Limited\n views of the lung fields demonstrate no change from earlier in the day.\n\n IMPRESSION: Right-sided PICC line is coiled in the right axilla and needs to\n be removed or repositioned.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891083, "text": " 5:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for PNA\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF s/p MRSA PNA now s/p trach.\n REASON FOR THIS EXAMINATION:\n Please evaluate for PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: COPD and MRSA pneumonia.\n\n IMPRESSION: AP chest compared to and 28:\n\n Right PICC line has been removed. Tip of the left subclavian line projects\n over the junction of the brachiocephalic veins. Tracheostomy tube in standard\n placement. Mild pulmonary edema, moderate left and small right pleural\n effusion have all improved. Consolidation at the left lung base is also\n better. There is no pneumothorax. Borderline cardiomegaly is stable but\n mediastinal venous engorgement is less pronounced.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888629, "text": " 5:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? improving edema\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated\n\n REASON FOR THIS EXAMINATION:\n ? improving edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:55 A.M \n\n HISTORY: COPD and CHF. Pneumonia. Intubated.\n\n IMPRESSION: AP chest compared to \n\n Most of the right lower chest is excluded from the study. Left lung shows a\n central consolidation at the base and moderate-to-large left pleural effusion\n worsened since yesterday. Heart is top normal size. Mediastinal vasculature\n remains markedly dilated indicating elevated central venous pressure or\n volume. Tip of the left subclavian infusion port projects over the SVC. ET\n tube is in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889278, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for increased pulmonary edema, pna\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter\n REASON FOR THIS EXAMINATION:\n please eval for increased pulmonary edema, pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD. Pneumonia. Left subclavian catheter.\n\n IMPRESSION: AP chest compared to and 14:\n\n ET tube in standard placement. Nasogastric tube passes below the diaphragm\n and out of view. Extensive consolidation in both lungs is due largely to\n pulmonary edema, not appreciably changed since , worsened since\n . More focal areas of consolidation in the perihilar left mid lung\n could be pneumonia. Small bilateral pleural effusion is presumed. Heart size\n remains top normal. Mediastinal vascular distention has improved.\n\n Tip of the left subclavian line projects over the left brachiocephalic vein.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889424, "text": " 5:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? improvement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter\n REASON FOR THIS EXAMINATION:\n ? improvement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:28 A.M \n\n HISTORY: Pneumonia and CHF.\n\n IMPRESSION: AP chest compared to and 15:\n\n Moderate to severe pulmonary edema has worsened since 7:11 a.m. on . Underlying pneumonia cannot be excluded. Heart size remains top normal\n but mediastinal vascular engorgement has worsened. ET tube is in standard\n placement. Nasogastric tube can be traced as far as the lower esophagus but\n the tip cannot be seen. At least small bilateral pleural effusions are\n present. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889588, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter.. unable to extubate\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old male patient with COPD and CHF with MRSA pneumonia.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The patient has underlying severe emphysema. There are continued opacities in\n the left lower lobe and right lower lobe indicating superimposed pneumonia.\n The previously identified pulmonary edema has been a slightly improving.\n There is continued cardiomegaly and small bilateral pleural effusion.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n left subclavian IV catheter terminates in the superior vena cava. A\n nasogastric tube courses toward the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889019, "text": " 6:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated s/p insertion of left\n subclavian catheter\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of intubation and CV line placement in a patient with MRSA infection.\n\n Endotracheal tube is 6 cm above carina. Left subclavian CV line has the tip\n located at the junction of the left brachiocephalic vein and SVC. No\n pneumothorax. There are bilateral pulmonary opacities diffusely distributed\n with some sparing all over the lung apicis consistent with a combination of\n layering pleural effusions and underlying pulmonary space consolidation,\n essentially unchanged since the previous film of .\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 888945, "text": " 2:01 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for abscess, hyrdonephrosis\n Admitting Diagnosis: HYPOXIA\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old M with CHF, COPD, respiratory failure. now with increasing white\n count and no source. ARF\n REASON FOR THIS EXAMINATION:\n eval for abscess, hyrdonephrosis\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive heart failure, COPD, and respiratory failure. Increasing\n white blood cell count. Acute renal failure. Evaluate for abscess or\n hydronephrosis.\n\n COMPARISON: No previous CT scan.\n\n TECHNIQUE: Axial multidetector CT images of the chest, abdomen and pelvis\n were obtained with oral contrast only. Intravenous contrast was withheld due\n to the patient's acute renal failure.\n\n CHEST CT WITHOUT CONTRAST: There is diffuse advanced emphysema. There are\n consolidations in both lower lobes. Small patchy peripheral opacities are\n present in the upper and middle lobes bilaterally. There are small-to-\n moderate bilateral pleural effusions. There is a 12 mm pretracheal lymph\n node, which may be reactive. The airways are patent to the level of segmental\n bronchi. The patient is intubated, with the endotracheal tube tip in good\n position between the thoracic inlet and the carina. Extensive atherosclerotic\n calcifications are present in the aorta and coronary arteries, as well as at\n the origins of the aortic arch branches. There is no pericardial effusion.\n\n ABDOMEN CT WITHOUT CONTRAST: The nasogastric tube terminates in the proximal\n stomach, abutting the gastric wall. The liver, spleen, pancreas, and adrenal\n glands appear unremarkable on limited non-contrast evaluation. The patient is\n status post cholecystectomy. There is no hydronephrosis. Extensive\n atherosclerotic vascular calcifications are present. There is nonspecific fat\n stranding in the paracolic gutters, which may be related to edema in the\n setting of congestive heart failure. There is no free air, free fluid, or\n evidence of an abscess.\n\n PELVIS CT WITHOUT CONTRAST: There is retroperitoneal fat stranding anterior\n to the common iliac arteries bilaterally, which extends bilaterally along the\n external iliac arteries. This appears nonspecific, and may represent atypical\n manifestation of edema related to congestive heart failure. There is no free\n fluid or evidence of an abscess. There are multiple diverticula in the colon\n without evidence of diverticulitis. There is no evidence of acute\n appendicitis. Small bowel loops appear unremarkable. There is a Foley\n catheter in the bladder. The prostate, seminal vesicles and rectum appear\n (Over)\n\n 2:01 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for abscess, hyrdonephrosis\n Admitting Diagnosis: HYPOXIA\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable.\n\n BONE WINDOWS: Mild degenerative changes are noted in the sacroiliac joints.\n Ossification is noted in the left obturator internus other adjacent muscles,\n suggestive of previous injury.\n\n IMPRESSION:\n\n 1. Bilateral multifocal pneumonia.\n\n 2. Small-to-moderate bilateral pleural effusions.\n\n 3. Nonspecific pelvic retroperitoneal fat stranding, which may be related to\n edema in the setting of congestive heart failure.\n\n 4. Diverticulosis without evidence of acute diverticulitis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888890, "text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated s/p\n insertion of left subclavian catheter\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n CLINICAL DETAILS: COPD, back stroke, CHF, with MRSA pneumonia.\n\n Comparison is made to previous imaging.\n\n ET tube in situ, the inferior tip of which is not clearly demonstrated on the\n current film but appeared normal on the preceding one. The tip of the left\n subclavian central line is projected over the medial aspect of the\n brachiocephalic level. Nasogastric tube in situ, the inferior tip is not\n demonstrated.\n\n Technically, the film is suboptimal but there is increased prominence of the\n central pulmonary vasculature bilaterally, more marked on the right side\n suggestive of pulmonary edema. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888425, "text": " 1:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please check ETT placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated\n\n REASON FOR THIS EXAMINATION:\n please check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, congestive heart failure, MRSA pneumonia, repositioning of\n endotracheal tube.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 4 hours earlier.\n The endotracheal tube has been repositioned and is now properly situated with\n tip 4.5 cm from the carina, at the thoracic inlet. The orogastric tube passes\n below the level of the film into the stomach. The left internal jugular vein\n catheter is unchanged in position. The appearance of lungs and cardiac\n silhouette are unchanged.\n\n IMPRESSION:\n\n Endotracheal tube repositioning with tip properly situated at the thoracic\n inlet. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889120, "text": " 6:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? improvment in edema\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated s/p insertion of left\n subclavian catheter\n REASON FOR THIS EXAMINATION:\n ? improvment in edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:47 A.M., \n\n HISTORY: COPD. MRSA pneumonia. Left subclavian line insertion.\n\n IMPRESSION: AP chest compared to and 13:\n\n Moderate-sized left pleural effusion has increased in volume loss. Small\n right pleural effusion is stable. However, heart size is top normal.\n Mediastinal vascular engorgement has progressed. Opacification in both lungs\n may be due to edema alone, worsened slightly since . Tip of the\n new left subclavian venous catheter projects over the SVC. No pneumothorax.\n ET tube in standard placement. Nasogastric tube passes below the diaphragm\n and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890505, "text": " 5:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate/effusion\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left\n subclavian catheter. s/p trach\n REASON FOR THIS EXAMINATION:\n r/o infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: COPD, CHF.\n\n CHEST: A single portable view is compared to previous examination of . As seen on the previous exam, there is cardiomegaly with\n pulmonary edema. The pulmonary edema is superimposed on chronic changes of\n COPD. There is a small right pleural effusion. The left costophrenic sulcus\n is not included on the film.\n\n A tracheostomy tube and left subclavian line with the tip over the junction of\n brachiocephalic veins are noted.\n\n IMPRESSION: COPD, cardiomegaly with marked pulmonary edema, no significant\n change since the previous exam a day ago.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2181-10-11 00:00:00.000", "description": "LP UNILAT UP EXT VEINS US LEFT PORT", "row_id": 888721, "text": " 2:30 PM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: LTRM SWELLING\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with left arm swelling.\n REASON FOR THIS EXAMINATION:\n please evaluate for dvt/.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left arm swelling.\n\n LEFT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler ultrasound of the left\n internal jugular, subclavian, axillary, brachial, basilic, and cephalic vein\n was performed. There is echogenic thrombus within the left internal jugular\n vein, which does not fill the entire lumen. There is peripheral flow within\n the internal jugular vein. The subclavian, axillary, brachial, basilic, and\n cephalic veins have normal compression, waveforms, and augmentation.\n\n IMPRESSION: Non-occlusive thrombus in the left internal jugular vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890063, "text": " 6:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 yo M with COPD/CHF with MRSA pneumonia, intubated, left subclavian\n catheter. Unable to extubate. trach tomorrow.\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:45 A.M. ON \n\n HISTORY: COPD, CHF and pneumonia. Intubated. Left subclavian line.\n\n IMPRESSION: PA and lateral chest compared to -19:\n\n Mild-to-moderate pulmonary edema has improved. Large areas of consolidation\n persist in the perihilar portions of both lungs and perhaps at the right lung\n base. Small-to-moderate bilateral pleural effusion persists. Heart is normal\n size. Mild vascular engorgement of the mediastinum is stable. Endotracheal\n tube is in standard placement. Nasogastric tube passes below the diaphragm\n and out of view. Tip of a left subclavian line projects over the\n brachiocephalic vein. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-08 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 888323, "text": " 7:01 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please do lower chest upper abdomen to assess OG tube placem\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CHF, COPD, OSA intubayed s/p OG placement\n REASON FOR THIS EXAMINATION:\n Please do lower chest upper abdomen to assess OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man with CHF, COPD, and OG tube placement.\n\n ABDOMEN, SINGLE VIEW: Tip of the feeding tube in the proximal stomach. The\n side port of the feeding tube is not visualized and probably lies just above\n the GE junction. Left- sided pleural effusion is present.\n\n" }, { "category": "Radiology", "chartdate": "2181-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888384, "text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please do chest and abdomen film to check OG tube placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated\n\n REASON FOR THIS EXAMINATION:\n please do chest and abdomen film to check OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, CHF, with pneumonia, intubated.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of one day earlier.\n The endotracheal tube is changed in position, and now lies with tip 1 to 1.5\n cm above the carina. An orogastric tube is present which passes out of site\n into the stomach. The cardiomediastinal silhouette is stable. There is\n vascular engorgement and slight increased opacity in the left mid and lower\n lung zones and in the right lower lung zone. There is no pneumothorax. There\n is a left-sided internal jugular central venous catheter with tip projecting\n over the left upper mediastinum, unchanged from multiple prior studies. The\n position of this catheter was discussed with Dr. on .\n\n IMPRESSION:\n 1. Endotracheal tube position low with tip 1 to 1.5 cm from the carina.\n 2. Increased opacity in the lower left mid and lower lung zones and the right\n lower lung zone likely secondary to asymmetric worsening pulmonary edema.\n 3. Orogastric tube positioned in the stomach.\n\n These results were communicated to Dr. at 12 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2181-10-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 888593, "text": " 5:38 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated s/p\n insertion of left subclavian catheter. (Left IJ still in place.)\n\n REASON FOR THIS EXAMINATION:\n line placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with COPD, CHF and MRSA pneumonia, intubated. Left\n subclavian catheter just placed. Assess placement.\n\n COMPARISON: at 07:15.\n\n SUPINE AP CHEST: The endotracheal tube as well as the left internal jugular\n central venous catheter remain in place. There has been interval placement of\n a left subclavian central venous catheter. The tip of the left subclavian\n catheter projects over the superior vena cava. No pneumothorax is identified\n on this supine radiograph. An NG tube is noted, to the retrocardiac level,\n where it becomes obscured. Once again, the extreme lung bases are excluded\n from the radiograph. With this limitation in mind, cardiac and mediastinal\n contours are stable. Diffuse opacity/infiltrates in both lungs, consistent\n with the given history, is relatively unchanged.\n\n IMPRESSION: Satisfactorily positioned left subclavian central venous\n catheter. No pneumothorax identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888318, "text": " 5:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p OG placement\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated\n\n REASON FOR THIS EXAMINATION:\n s/p OG placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man with COPD/CHF with MRSA pneumonia. Intubated\n status post OG tube placement.\n\n COMPARISON: 11 hours earlier.\n\n CHEST AP: Stable appearance of heterogeneous opacification of the lungs which\n could represent pneumonia and/or pulmonary edema superimposed upon underlying\n COPD. There is stable appearance of bilateral pleural effusions. An\n endotracheal tube is seen with its tip about 5 cm above the carina. The tip\n of the OG tube is not visualized due to underpenetration. A left-sided IJ\n line is seen which does not follow normal left brachiocephalic vein and could\n be present in a persistent left-sided superior vena cava. Please see comments\n in report of prior CXR today.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888803, "text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with COPD/CHF with MRSA pneumonia, intubated s/p\n insertion of left subclavian catheter. (Left IJ still in place.)\n\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:12 A.M., \n\n HISTORY: COPD and CHF. MRSA pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Mild pulmonary edema has improved. Pleural effusion if present is small. The\n heart is normal size. Left subclavian line tip projects over the SVC. ET\n tube is in standard placement and a nasogastric tube can be traced only as far\n as the lower esophagus where the tip becomes indistinct. There is no\n pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2181-10-14 00:00:00.000", "description": "Report", "row_id": 298809, "text": "Atrial fibrillation\nLow limb lead QRS voltages - is nonspecific\nSince previous tracing of , atrial fibrillation now present\n\n" }, { "category": "ECG", "chartdate": "2181-10-10 00:00:00.000", "description": "Report", "row_id": 298810, "text": "Baseline artifact\nSinus rhythm with sinus arrhythmia and atrial premature complexes\nConsider left atrial abnormality\nLow limb lead QRS voltages - is nonspecific\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2181-10-09 00:00:00.000", "description": "Report", "row_id": 298811, "text": "Baseline artifact\nSinus rhythm with probable sinus arrhythmia and atrial premature complexes\nConsider left atrial abnormality\nLow limb lead QRS voltages - is nonspecific\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2181-10-07 00:00:00.000", "description": "Report", "row_id": 298812, "text": "Normal sinus rhythm, rate 59. Low voltage in standard leads. Minor non-specific\nrepolarization changes. Compared to the previous tracing of sinus rate\nis slower.\n\n" }, { "category": "ECG", "chartdate": "2181-10-01 00:00:00.000", "description": "Report", "row_id": 298813, "text": "Sinus rhythm with borderline resting sinus tachycardia and atrial premature\nbeats. Relatively low voltage diffusely. P-R interval at the upper limits of\nnormal. No previous tracing available for comparison. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2181-10-21 00:00:00.000", "description": "Report", "row_id": 298807, "text": "Sinus rhythm. Borderline low QRS voltage in the limb leads. Ventricular\npremature depolarizationss. Non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of cardiac now sinus mechanism.\n\n" }, { "category": "ECG", "chartdate": "2181-10-17 00:00:00.000", "description": "Report", "row_id": 298808, "text": "Atrial fibrillation with a mean ventricular response, rate 92. Borderline low\nQRS voltage in the limb leads. Compared to the previous tracing of no\nmajor change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2190-06-30 00:00:00.000", "description": "Report", "row_id": 98033, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 65\nWeight (lb): 126\nBSA (m2): 1.63 m2\nBP (mm Hg): 111/52\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 11:35\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLeft pleural effusion seen.\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. Mild\nto moderate (+) mitral regurgitation is seen. The tricuspid valve leaflets\nare mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion. There are\nno echocardiographic signs of tamponade.\n\n\n" }, { "category": "Nursing", "chartdate": "2190-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382583, "text": "SICU\n HPI:\n 89F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Atrial fibrillation (Afib)\n Assessment:\n Heart rate 60-80\ns normal sinus rhythmn. Pvc\ns seen. Amiodarone gtt\n infusing at 0.5mg/hr till o500am\n Action:\n Levophed gtt has remained off this shift, amiodarone gtt decreased\n to0.5mg/hr for 18hrs. and stopped at 0500am\n Electrolytes repleted.\n Response:\n Amiodarone gtt off this am at 0500am and remains in normal sinus\n rhythmn\n Plan:\n Monitor heart rate ,rhythmn and ectopy\n Po amiodarone to be started today.\n Delirium / confusion\n Assessment:\n Confused all shift, pulled saline out, pulled her foley catheter\n out with balloon still inflated.\n Becoming slightly agitated.\n Moving legs out of bed.\n Dr notified and in to see patient.\n Action:\n Geriatric consult answered.\n Reoriented frequently.\n Bed alarm on\n Bed in low position.\n Haldol 0.5mg iv given\n Response:\n Confused.\n Plan:\n Reorient frequently\n Bed position in low position\n Bed alarm on.\n Update family.\n" }, { "category": "Physician ", "chartdate": "2190-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 382586, "text": "SICU\n HPI:\n 89F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Current medications:\n . 2. 3. Acetaminophen 4. Amiodarone 5. Amiodarone 6. Atorvastatin 7.\n Calcium Gluconate 8. Docusate Sodium 9. Haloperidol 10. Heparin 11.\n Insulin 12. Lansoprazole Oral Disintegrating Tab 13. Lidocaine 5% Patch\n 14. Magnesium Sulfate 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Morphine Sulfate 18. Norepinephrine 19. Piperacillin-Tazobactam 20.\n Potassium Chloride 21. Senna 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n TRANSTHORACIC ECHO - At 10:50 AM\n EKG - At 12:57 PM\n ULTRASOUND - At 04:30 PM\n Haldol for agitation, pulled foley out. IP did not place a second\n pigtail in apical collection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:10 AM\n Famotidine (Pepcid) - 08:58 AM\n Heparin Sodium (Prophylaxis) - 01:54 AM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.3\nC (97.4\n HR: 80 (60 - 119) bpm\n BP: 152/74(105) {73/40(55) - 158/100(108)} mmHg\n RR: 18 (18 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58 kg (admission): 57 kg\n CVP: 8 (4 - 12) mmHg\n Total In:\n 1,892 mL\n 154 mL\n PO:\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,532 mL\n 154 mL\n Blood products:\n Total out:\n 980 mL\n 125 mL\n Urine:\n 800 mL\n 125 mL\n NG:\n Stool:\n Drains:\n 180 mL\n Balance:\n 912 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: 7.43/30/90./20/-2\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: No(t) Rash:\n Neurologic: (Awake / Alert / Oriented: x 2, x 1), Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 649 K/uL\n 10.7 g/dL\n 102 mg/dL\n 0.5 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 114 mEq/L\n 143 mEq/L\n 31.6 %\n 27.0 K/uL\n [image002.jpg]\n 06:21 PM\n 01:13 AM\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n WBC\n 48.3\n 35.8\n 27.0\n Hct\n 36.0\n 30.8\n 31.6\n Plt\n 821\n 634\n 649\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n Troponin T\n <0.01\n TCO2\n 19\n 17\n 21\n Glucose\n 84\n 92\n 80\n 94\n 140\n 102\n Other labs: PT / PTT / INR:17.6/49.6/1.6, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL, LDH:208 IU/L,\n Ca:8.2 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC, ATRIAL FIBRILLATION (AFIB), DELIRIUM /\n CONFUSION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SEPSIS WITHOUT\n ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neuro: alert, haldol for agitation, morphine for pain\n CVS: Afib resolved, levo off, amiodarone started\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc /Zosyn,\n pleural fluid cx sent, on NC\n GI: bowel regimen, home PPI\n FEN: KVO, reg diet\n Renal: Borderline UOP 10+cc/hr. Will start lasix\n Heme: on SCH for proph\n Endo: RISS\n ID: Febrile, WC 36.5, w/ LS, Vanc/Zosyn, check trough 7.8. Will\n increase dose to 1gram every 12 hrs\n TLD: D/C A-line, TLC , pigtail, CVL, pigtail\n Wounds: none\n Imaging: CXR P\n Prophylaxis: SCH, boots, PPI\n Consults: thoracic\n Code: FULL\n Disposition: SICU\n Consults: Pulmonology, Geriatrics, Thoracic Surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure)\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:30 PM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2190-06-30 00:00:00.000", "description": "Intensivist Note", "row_id": 382460, "text": "SICU\n HPI:\n 89 F w/ loculated pleural effusion s/p pigtail placement now in Afib\n Chief complaint:\n SOB\n PMHx:\n PMH: Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease\n Current medications:\n 1. 250 mL NS 2. Acetaminophen 3. Amiodarone 4. Amiodarone 5. Amiodarone\n 6. Calcium Gluconate 7. Docusate Sodium\n 8. Famotidine 9. Fentanyl Citrate 10. Furosemide 11. Haloperidol 12.\n Heparin 13. Insulin 14. Magnesium Oxide\n 15. Magnesium Sulfate 16. Metoprolol Tartrate 17. Morphine Sulfate 18.\n Neutra-Phos 19. Norepinephrine\n 20. Piperacillin-Tazobactam 21. Potassium Chloride 22. Vancomycin\n 24 Hour Events:\n CHEST TUBE PLACED - At 05:42 PM\n ARTERIAL LINE - START 06:30 PM\n EKG - At 02:15 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:51 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:45 PM\n Heparin Sodium (Prophylaxis) - 12:28 AM\n Metoprolol - 02:15 AM\n Diltiazem - 03:47 AM\n Furosemide (Lasix) - 03:47 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.1\nC (98.8\n HR: 128 (76 - 134) bpm\n BP: 93/50(63) {93/41(59) - 136/56(83)} mmHg\n RR: 26 (22 - 33) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 5,035 mL\n 469 mL\n PO:\n Tube feeding:\n IV Fluid:\n 785 mL\n 469 mL\n Blood products:\n Total out:\n 448 mL\n 104 mL\n Urine:\n 198 mL\n 104 mL\n NG:\n Stool:\n Drains:\n 250 mL\n Balance:\n 4,587 mL\n 365 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: 7.39/30/103/19/-5\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 634 K/uL\n 10.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 114 mEq/L\n 142 mEq/L\n 30.8 %\n 35.8 K/uL\n [image002.jpg]\n 06:21 PM\n 01:13 AM\n 03:46 AM\n WBC\n 48.3\n 35.8\n Hct\n 36.0\n 30.8\n Plt\n 821\n 634\n Creatinine\n 0.5\n 0.5\n Troponin T\n <0.01\n TCO2\n 19\n Glucose\n 84\n 92\n 80\n Other labs: PT / PTT / INR:17.6/49.6/1.6, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Ca:7.1 mg/dL, Mg:1.5 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neuro: alert, haldol for agitation, morphine for pain\n CVS: Afib O/N, hypotension w/ metoprolol, amiodarone started, repeat\n EKG, CE's, TSH P\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc/Zosyn,\n pleural fluid cx sent, on NC, IR to drain remaining abscesses \n GI: bowel regimen, home PPI\n FEN: LR 100, NPO x meds, replete lytes\n Renal: euvolemic, u/o 30-100, LOS +5L\n Heme: stable Hct 42.8, on SCH, INR 1.1\n Endo: RISS\n ID: Febrile, WC 36.5, w/ LS, Vanc/Zosyn\n TLD: Aline, PIVx2\n Wounds: none\n Imaging: CXR P\n Prophylaxis: SCH, boots, PPI\n Consults: thoracic\n Code: FULL\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:38 PM\n Arterial Line - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 37 minutes\n" }, { "category": "Rehab Services", "chartdate": "2190-07-01 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 382592, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION\n HISTORY\n Thank you for referring this 89 year old woman admitted on with\n right flank pain. CT showing right sided loculated pleural effusion,\n likely empyema. She is s/p pigtail placement. CXR this morning was\n without significant change with no focal consolidation. We were\n consulted to evaluate pt's oral and pharyngeal swallow function to\n determine the safest diet. RN, refusing all PO this morning.\n Chewed pills with no liquid or solid washdown.\n Pt is known to our department by a bedside swallowing evaluation in\n , at which time she was cleared for PO diet of regular solids and\n thin liquids.\n PAST MEDICAL HISTORY:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation, no longer on antiarrhythmic or\n anticoagulation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Hernia repair\n s/p appy\n Degenerative disc disease followed by ortho\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the bed on SICU B. Pt kyphotic and restless, difficult to maintain\n upright position.\n Cognition, language, speech, voice:\n Awake, alert. Responds to her name but otherwise not oriented.\n Significantly confused, talking near constantly, no consistent topic.\n Language fluent. Speech and voice WNL. Does not follow commands.\n Teeth: fair- good condition\n Secretions: teeth coated with chalky substance (?chewed meds given by\n RN earlier)\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Given poor compliance, unable to formally\n assess otherwise.\n SWALLOWING ASSESSMENT:\n Pt offered thin liquid (attempted straw, successful drop-straw), ice\n cream (considered a thin liquid), and small bites of cracker.\n oral phase remarkable for talking with PO in her mouth, prolonged\n chewing of cracker and mild-moderate oral cavity residue\n requiring multiple f/u sips/bites of ice cream to clear. Laryngeal\n elevation could not be palpated pt participation. No throat\n clearing, coughing, choking, or vocal quality changes during or after\n these limited PO trials. Pt's O2 sats fluctuated between 97-94% during\n eval (with poor pleth) without overt association with PO intake.\n SUMMARY / IMPRESSION:\n Results of today's evaluation are limited and not fully reliable given\n limited participation in evaluation. However, in limited trials, pt\n did not present with any s/sx of aspiration. Pt recommended for diet\n downgrade to ground solids and thin liquids with PO meds continued\n chewed/crushed, preferably with puree or ice cream. Nutrition f/u\n recommended, as in pt's current state, she does not appear able to\n maintain full oral nutrition. If pt's overall condition improves such\n that diet upgrade would be reasonable or if there are further concerns\n for aspiration or other oropharyngeal dysphagia, please do not hesitate\n to reconsult for repeat evaluation.\n This swallowing pattern correlates to a Dysphagia Outcome\n Severity Scale (DOSS) rating of 4, mild-moderate dysphagia.\n RECOMMENDATIONS:\n 1. PO diet: ground solids, thin liquids\n 2. PO meds crushed in puree or ice cream\n 3. Q4 oral care, as able.\n 4. 1:1 assist with PO to encourage intake and maintain standard\n aspiration precautions.\n 5. Nutrition f/u\n 6. Please page/reconsult if we can be of further assistance.\n These recommendations were shared with the patient, nurse and medical\n team.\n ____________________________________\n M.S., CCC-SLP\n Pager # \n Face time: 10:25-10:50\n Total time: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2190-07-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382680, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases. Audible expiratory wheezing this am\n after repositioning. O2 sat 95-97% on 2.5l nc. Chest tube beginning to\n drain more sanginous following repositioning this am, about 210cc\n overnight. + fluctuation, no crepitus or leak noted.\n Action:\n Nebs given PRN by RT. Chest tube drainage shown to thoracic resident as\n well as Dr. . Will get chest xray this am\n Response:\n Pt breathing comfortably.\n Plan:\n Continue to monitor output, follow up on chest x-ray, continue nebs as\n needed\n Delirium / confusion\n Assessment:\n Pt remains confused, appears to be hallucinating. Not answering\n questions appropriately and not always looking at RN when spoken to.\n Agitated at times, refusing meds. Moving all ext. combative at times.\n L pupil appearing to be fixed and dilated this am, R pupil brisk. ?\n change, not noted until this point.\n Action:\n Seroquel given for sleep. Dr. and thoracic resident shown\n pupils and performed neuro exam. NMED resident consulted and pupil\n believed to be surgical.\n Response:\n Pt remains confused and delirious, Seroquel uneffective\n Plan:\n ? need for CT, possibly increased Seroquel\n" }, { "category": "Physician ", "chartdate": "2190-07-02 00:00:00.000", "description": "Intensivist Note", "row_id": 382697, "text": "SICU\n HPI:\n F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n flank pain\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 4. Acetaminophen 5.\n Alteplase 6. Albuterol 0.083% Neb Soln\n 7. Amiodarone 8. Atorvastatin 9. Calcium Gluconate 10. Docusate Sodium\n 11. Furosemide 12. Heparin\n 13. Insulin 14. Lansoprazole Oral Disintegrating Tab 15. Lidocaine 5%\n Patch 16. Magnesium Sulfate\n 17. Magnesium Sulfate 18. Metoprolol Tartrate 19. Metoprolol Tartrate\n 20. Morphine Sulfate 21. Norepinephrine\n 22. Piperacillin-Tazobactam 23. Potassium Chloride 24. Quetiapine\n Fumarate 25. Senna 26. Sodium Chloride 0.9% Flush\n 27. Sodium Phosphate 28. Tiotropium Bromide 29. Vancomycin 30.\n Venlafaxine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:20 AM\n EKG - At 11:45 AM\n tpa to chest tube, had desat episode w/ tachypnea, got\n albuterol+atrovent + lasix, later developed fixed and dilated left\n pupil, got neuro consult\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:26 AM\n Furosemide (Lasix) - 04:01 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.7\nC (98\n HR: 71 (65 - 104) bpm\n BP: 114/44(62) {97/38(56) - 149/110(116)} mmHg\n RR: 20 (18 - 31) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.1 kg (admission): 57 kg\n CVP: 3 (2 - 9) mmHg\n Total In:\n 881 mL\n 142 mL\n PO:\n Tube feeding:\n IV Fluid:\n 881 mL\n 142 mL\n Blood products:\n Total out:\n 981 mL\n 90 mL\n Urine:\n 871 mL\n 90 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -100 mL\n 52 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), No(t) Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), Moves all\n extremities, pt is confused, does not follow commands\n Labs / Radiology\n 665 K/uL\n 9.8 g/dL\n 116 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 16 mg/dL\n 113 mEq/L\n 144 mEq/L\n 30.3 %\n 29.4 K/uL\n [image002.jpg]\n 06:21 PM\n 01:13 AM\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n WBC\n 48.3\n 35.8\n 27.0\n 29.4\n Hct\n 36.0\n 30.8\n 31.6\n 30.3\n Plt\n 821\n 634\n 649\n 665\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n Troponin T\n <0.01\n TCO2\n 19\n 17\n 21\n Glucose\n 84\n 92\n 80\n 94\n 140\n 102\n 101\n 116\n Other labs: PT / PTT / INR:16.3/44.5/1.4, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL, LDH:208 IU/L,\n Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neurologic: alert, seroquel for agitation /insomnia x1 ordered,\n morphine for pain\n Cardiovascular: Afib O/N, off levo, amiodarone PO started, metoprolol\n started () (QT: 0.424)\n Pulmonary: empyema from PNA, s/p pigtail placement by IP, on\n Vanc/Zosyn, pleural fluid cx sent, no further intervention on apical\n effusion per thoracics, TPA given via pigtail , episode of desat\n and tachypnea yesterday afternoon responding to nebs + lasix\n Gastrointestinal / Abdomen: bowel regimen, home PPI\n Nutrition: confused and not taking PO, KVO for now d/t concerns of vol\n overload,\n Renal: Marginal UOP but repsonded to lasix\n Hematology: on SCH for proph\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn for loculated pleural effusions, check\n trough AM , f/u cx\n Lines / Tubes / Drains: foley, RSC CVL, pigtail\n Consults: thoracic, ID, thoracics\n Billing Diagnosis:\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments: SCH, boots, PPI\n Communication: Comments:\n Code status:\n Disposition: SICU\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2190-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382575, "text": "SICU\n HPI:\n 89F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Atrial fibrillation (Afib)\n Assessment:\n Heart rate 60-80\ns normal sinus rhythmn. Pvc\ns seen. Amiodarone gtt\n infusing at 0.5mg/hr till o500am\n Action:\n Levophed gtt has remained off this shift, amiodarone gtt decreased\n to0.5mg/hr for 18hrs. and stopped at 0500am\n Electrolytes repleted.\n Response:\n Amiodarone gtt off this am at 0500am and remains in normal sinus\n rhythmn\n Plan:\n Monitor heart rate ,rhythmn and ectopy\n Po amiodarone to be started today.\n Delirium / confusion\n Assessment:\n Confused all shift, pulled saline out, pulled her foley catheter\n out with balloon still inflated.\n Becoming slightly agitated.\n Moving legs out of bed.\n Dr notified and in to see patient.\n Action:\n Geriatric consult answered.\n Reoriented frequently.\n Bed alarm on\n Bed in low position.\n Haldol 0.5mg iv given\n Response:\n Confused.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382456, "text": "Delirium / confusion\n Assessment:\n Pt was alert and oriented at the beginning of the shift with some mild\n intermittent confusion noted. At midnight, pt woke from sleep and\n became slightly combative, confused and refused care.\n Action:\n Dr. notified, pt monitored closely for safety and approached\n several times for reevaluation.\n Response:\n Confusion lessening at 2 am when waking pt, pleasant and cooperative\n Plan:\n Continue to monitor mental status, orient when necessary, provide\n emotional support\n Sepsis without organ dysfunction\n Assessment:\n BP stable at beginning of the shift, remained 100-130 systolic most of\n the night while in sinus rhythm. UOP minimal, 20-30 cc/hr. WBCs\n trending down this am. Tmax 99 axillary, pt not cooperating for oral\n temp.\n Action:\n Levo weaned down and stopped at beginning of the shift. Many\n conversations had with SICU and Thoracic team regarding Lasix vs.\n fluid. Decision made for small fluid bolus and if UOP decreases below\n 20cc/hr, lasix to be ordered. Zosyn and Vanco started.\n Response:\n Sepsis resolving\n Plan:\n Continue to monitor white count, temp, BP and need for pressors.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o lower ext pain that she states is not new. Also c/o intermittent\n pain in right upper back area consistent with area of chest tube\n Action:\n Repositioned frequently, Morphine 2mg and Tylenol given\n Response:\n Pt responding best to Tylenol, Morphine not lasting long enough.\n Plan:\n Continue to offer pain relief with po, iv meds and repostioning\n Atrial fibrillation (Afib)\n Assessment:\n Pt converting to rapid a-fib this am, rate 120-150.\n Action:\n Lopressor 5mg given x 1, EKG done, labs sent\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382766, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt with acute and chronic pain issues, currently related to turning,\n C+DB etc.\n Action:\n medicated with Tylenol Q8hrs, repositioned\n Response:\n slight relief from pain, able to sleep for few hours between\n interventions\n Plan:\n continue to medicate as ordered. Needs pain service consult\n Delirium / confusion\n Assessment:\n pt remains confused to time and place mostly.\n Action:\n regular neuro checks\n Response:\n unchanged exam currently\n Plan:\n continue to monitor for changes in mental status.\n" }, { "category": "Physician ", "chartdate": "2190-07-03 00:00:00.000", "description": "Intensivist Note", "row_id": 382772, "text": "SICU\n HPI:\n F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n Empyema\n PMHx:\n PMH: Frequent Falls , CAD - s/p MI years ago , CHF - ? last ECHO\n EF 70% , Atrial fibrillation ,\n Chronic venous stasis with b/l lower extremity edema , Constipation,\n Degenerative disc disease followed by ortho\n PSH:Hernia repair, appy\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Alteplase 6.\n Amiodarone 7. Atorvastatin\n 8. Calcium Gluconate 9. Docusate Sodium 10. Furosemide 11. Heparin 12.\n Insulin 13. Lansoprazole Oral Disintegrating Tab 14. Lidocaine 5% Patch\n 15. Magnesium Sulfate 16. Magnesium Sulfate 17. Metoprolol Tartrate 18.\n Morphine Sulfate 19. Piperacillin-Tazobactam 20. Potassium Chloride 21.\n Quetiapine Fumarate 22. Senna 23. Sodium Chloride 0.9% Flush 24. Sodium\n Phosphate 25. Tiotropium Bromide 26. Vancomycin 27. Venlafaxine\n 24 Hour Events:\n : TPA (again). Blown pupil w/ lethargy. Head CT obtained. Waiting\n optho consult. Improved mental status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:53 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 59 (57 - 73) bpm\n BP: 96/40(54) {90/39(53) - 162/90(101)} mmHg\n RR: 20 (14 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 59.1 kg (admission): 57 kg\n Height: 65 Inch\n CVP: 1 (0 - 11) mmHg\n Total In:\n 890 mL\n 151 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 790 mL\n 151 mL\n Blood products:\n Total out:\n 850 mL\n 55 mL\n Urine:\n 440 mL\n 55 mL\n NG:\n Stool:\n Drains:\n 410 mL\n Balance:\n 40 mL\n 96 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Left pupil dilated, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), (Distant heart\n sounds: Absent)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Wheezes : ,\n Rhonchorous : , Diminished: Bases bilaterally)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, Not oriented. Waxing/ exam t/o day\n Labs / Radiology\n 700 K/uL\n 9.4 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.2 mEq/L\n 17 mg/dL\n 113 mEq/L\n 145 mEq/L\n 29.7 %\n 21.2 K/uL\n [image002.jpg]\n 01:13 AM\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n 03:21 AM\n WBC\n 35.8\n 27.0\n 29.4\n 21.2\n Hct\n 30.8\n 31.6\n 30.3\n 29.7\n Plt\n 634\n 649\n 665\n 700\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n 0.5\n TCO2\n 19\n 17\n 21\n Glucose\n 92\n 80\n 94\n 140\n 102\n 101\n 116\n 107\n Other labs: PT / PTT / INR:16.3/44.5/1.4, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL, LDH:208 IU/L,\n Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, RESPIRATORY FAILURE,\n CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neurologic: Alert, seroquel for agitation /insomnia, morphine for pain.\n Dilated L pupil. Normal head CT. Optho consulted\n Cardiovascular: Afib, on amiodarone PO and metoprolol (QT: 0.424)\n Pulmonary: Empyema from PNA, s/p pigtail placement by IP, on\n Vanc/Zosyn, pleural fluid cx sent, no further intervention on apical\n effusion per thoracics, TPA given via pigtail , \n Gastrointestinal / Abdomen: Bowel regimen, home PPI\n Nutrition: Speech and Swallow eval, Confused. Taking minimal PO.\n Renal: Foley, Marginal UOP. On home lasix.\n Hematology: on SCH for proph\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn for loculated pleural effusions, check\n trough\n Lines / Tubes / Drains: foley, RSC CVL, CT pigtail\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, Neurology, Geriatrics\n Billing Diagnosis: Arrhythmia, (Pneumonia due to procedure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382833, "text": "Delirium / confusion\n Assessment:\n Pt sleeping intermittently throughout the night, arousable to voice.\n Oriented to\n and person only. Can answer simple questions\n appropriately. Pupils equal, left appearing sluggish but reactive. No\n delirium noted this shift, pt is pleasant and only mildly confused at\n times. Moving all ext on the bed, following all commands.\n Action:\n Neuro assessment Q 4 hours. Reoriented at needed. Pt in calm quiet\n atmosphere\n Response:\n Pt resting comfortably throughout the shift\n Plan:\n Continue to monitor neuro status, reorient and offer emotional support\n as needed\n Problem - Description In Comments\n Assessment:\n Low UOP, 10-20cc for a few hours overnight.\n Action:\n Dr. notified, Lasix 10mg given IV x 1\n Response:\n Urine output improving,\n Plan:\n Continue to monitor uop and assess need for additional Lasix\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382904, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases.\n O2 sat 97-100% on 4 L nc\n Chest tube dry suction draining large amts serosang drainage\n Action:\n OOB to chair\n encouraged to cough/ deep breaths\n Response:\n Pt comfortable\n Resp status continues to improve\n Plan:\n Continue to monitor CT output\n nebs prn\n wean O2 as tolerated\n OOB to chair as tolerated\n transfer to floor in am, to rehab this week per Dr. \n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382454, "text": "Delirium / confusion\n Assessment:\n Pt was alert and oriented at the beginning of the shift with some mild\n intermittent confusion noted. At midnight, pt woke from sleep and\n became slightly combative, confused and refused care.\n Action:\n Dr. notified, pt monitored closely for safety and approached\n several times for reevaluation.\n Response:\n Confusion lessening at 2 am when waking pt, pleasant and cooperative\n Plan:\n Continue to monitor mental status, orient when necessary, provide\n emotional support\n Sepsis without organ dysfunction\n Assessment:\n BP stable at beginning of the shift, remained 100-130 systolic most of\n the night while in sinus rhythm. UOP minimal, 20-30 cc/hr. WBCs\n trending down this am. Tmax 99 axillary, pt not cooperating for oral\n temp.\n Action:\n Levo weaned down and stopped at beginning of the shift. Many\n conversations had with SICU and Thoracic team regarding Lasix vs.\n fluid. Decision made for small fluid bolus and if UOP decreases below\n 20cc/hr, lasix to be ordered. Zosyn and Vanco started.\n Response:\n Sepsis resolving\n Plan:\n Continue to monitor white count, temp, BP and need for pressors.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382832, "text": "Delirium / confusion\n Assessment:\n Pt sleeping intermittently throughout the night, arousable to voice.\n Oriented to\n and person only. Can answer simple questions\n appropriately. Pupils equal, left appearing sluggish but reactive. No\n delirium noted this shift, pt is pleasant and only mildly confused at\n times. Moving all ext on the bed, following all commands.\n Action:\n Neuro assessment Q 4 hours. Reoriented at needed. Pt in calm quiet\n atmosphere\n Response:\n Pt resting comfortably throughout the shift\n Plan:\n Continue to monitor neuro status, reorient and offer emotional support\n as needed\n" }, { "category": "Physician ", "chartdate": "2190-07-04 00:00:00.000", "description": "Intensivist Note", "row_id": 382874, "text": "SICU\n HPI:\n F w/ loculated pleural effusion s/p pigtail placement now in Afib\n Chief complaint:\n empyema\n PMHx:\n PMH: Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n PSH:Hernia repair, appy\n Current medications:\n 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Amiodarone 6.\n Atorvastatin 7. Calcium Gluconate 8. Docusate Sodium 9. Furosemide 10.\n Heparin 11. Insulin 12. Lansoprazole Oral Disintegrating Tab 13.\n Lidocaine 5% Patch 14. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Morphine Sulfate\n 18. Piperacillin-Tazobactam 20. Quetiapine Fumarate 21. Senna 24.\n Tiotropium Bromide 25. Vancomycin 26. Venlafaxine\n 24 Hour Events:\n EKG - At 02:04 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:35 AM\n Piperacillin/Tazobactam (Zosyn) - 11:56 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Furosemide (Lasix) - 12:30 AM\n Other medications:\n Flowsheet Data as of 04:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 64 (58 - 84) bpm\n BP: 124/84(95) {90/34(48) - 124/84(95)} mmHg\n RR: 20 (18 - 29) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.1 kg (admission): 57 kg\n Height: 65 Inch\n CVP: 0 (0 - 6) mmHg\n Total In:\n 900 mL\n 148 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 840 mL\n 148 mL\n Blood products:\n Total out:\n 955 mL\n 513 mL\n Urine:\n 495 mL\n 363 mL\n NG:\n Stool:\n Drains:\n 180 mL\n 150 mL\n Balance:\n -55 mL\n -365 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 802 K/uL\n 10.2 g/dL\n 109 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 16 mg/dL\n 113 mEq/L\n 144 mEq/L\n 30.7 %\n 26.2 K/uL\n [image002.jpg]\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n 03:21 AM\n 02:05 AM\n WBC\n 27.0\n 29.4\n 21.2\n 26.2\n Hct\n 31.6\n 30.3\n 29.7\n 30.7\n Plt\n 02\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n 0.5\n 0.5\n TCO2\n 19\n 17\n 21\n Glucose\n 80\n 94\n 140\n 102\n 101\n 116\n 107\n 109\n Other labs: PT / PTT / INR:15.0/41.0/1.3, CK / CK-MB / Troponin\n T:23//<0.01, Differential-Neuts:81.0 %, Band:1.0 %, Lymph:8.0 %,\n Mono:5.0 %, Eos:3.0 %, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL,\n LDH:208 IU/L, Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n BRADYCARDIA, PROBLEM - ENTER DESCRIPTION IN COMMENTS, RESPIRATORY\n FAILURE, CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE PAIN,\n CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 90 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neuro: Alert, seroquel for agitation /insomnia, morphine for pain.\n CVS: Afib, Now NSR will D/C amiodarone and if needed increase\n metoprolol (QT: 0.424)\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanco / Zosyn,\n pleural fluid cx sent, no further intervention on apical effusion per\n thoracics, TPA given via pigtail , \n GI: bowel regimen, home PPI\n FEN: Regular diet, KVO. On home lasix. Repleting electrolytes\n Renal: euvolemic, UOP 13-140, on home lasix.\n Heme: on SCH for proph. PTT is high. Will drop to twice daily.\n Endo: RISS\n ID: Vanc/Zosyn for loculated pleural effusions, trough is 12. Will\n increase dose to every 18 hours.\n TLD: foley, RSC CVL, CT pigtail\n Wounds: none\n Imaging:\n Prophylaxis: SCH, boots, PPI\n Consults: thoracic, ID, geriatrics, neuromed\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2190-07-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 383022, "text": "F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Respiratory failure, chronic\n Assessment:\n Patient continues to have pigtail chest tube in place to dry suction\n draining 50 cc serosanguinous fluid. Lungs sound diminished on right\n side, clear on left side. On 5 L NC. O2 sats 96-100%.\n Action:\n Continues on antibiotics however vanco discontinued,\n Patient encouraged to cough and deep breathe frequently, chest PT,\n OOB to chair,\n O2 weaned to 3 L NC.\n Response:\n O2 sats continue to be 96-100%, Patient denies SOB.\n Plan:\n Continue to monitor, transfer to 9 awaiting available bed, rehab?\n Delirium / confusion\n Assessment:\n Patient oriented x , although confused at times. Able to take po\n however coughing frequently.\n Action:\n - reoriented frequently,\n - speech and swallow called for a reevaluation.\n Response:\n Patient calm and easily reoriented,\n Patient did well with speech and swallow eval, able to have soft solids\n and thin liquids.\n Plan:\n Continue to monitor, reorient as needed.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n EMPYEMA\n Code status:\n Height:\n 65 Inch\n Admission weight:\n 57 kg\n Daily weight:\n 61 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CAD, CHF, MI\n Additional history: Syncope, MI years ago, Constipation,\n degenrerative disk disease, chronic venous stasis with bilateral leg\n edema.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:40\n Temperature:\n 96.7\n Arterial BP:\n S:154\n D:74\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 1,879 mL\n 24h total out:\n 735 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 11:30 AM\n Potassium:\n 3.8 mEq/L\n 02:04 AM\n Chloride:\n 109 mEq/L\n 02:04 AM\n CO2:\n 27 mEq/L\n 02:04 AM\n BUN:\n 17 mg/dL\n 02:04 AM\n Creatinine:\n 0.5 mg/dL\n 11:30 AM\n Glucose:\n 94 mg/dL\n 02:04 AM\n Hematocrit:\n 26.7 %\n 02:04 AM\n Finger Stick Glucose:\n 98\n 04:00 PM\n Valuables / Signature\n Patient valuables: Hearing aids: (Right Ear, Left Ear )\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 9\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2190-07-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382753, "text": "CHANGE IN NEURO STATUS:\n Problem - Description In Comments\n Assessment:\n Lethargic..moves all extrem\ns..Lt pupil sluggish & larger than\n Rt..confused to time & place but oriented to person & the fact that\n this is her Birthday today\n Action:\n Neuro consult..Head CT done\n Response:\n Head CT uneventful\n Plan:\n Neuro to follow pt..will check neuro signs q2-4h\n Delirium / confusion\n Assessment:\n Confused but cooperative\n Action:\n Family in to visit attempt to orient pt..will keep restraints on for\n now & no narcotics to be given per geriatics consult\n Response:\n Remains pleasantly confused will follow commands\n Plan:\n Orient frequenty remove restraints when able\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o of pain in back arms & legs with any movement\n Action:\n Position changed q2-3h..lidocaine patch on back..tylenol for pain\n Response:\n No real pain relief\n Plan:\n ? pain consult\n" }, { "category": "Physician ", "chartdate": "2190-06-30 00:00:00.000", "description": "Intensivist Note", "row_id": 382510, "text": "SICU\n HPI:\n 89 F w/ loculated pleural effusion s/p pigtail placement now in Afib\n Chief complaint:\n SOB\n PMHx:\n PMH: Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease\n Current medications:\n 1. 250 mL NS 2. Acetaminophen 3. Amiodarone 4. Amiodarone 5. Amiodarone\n 7. Docusate Sodium 8. Famotidine 9. Fentanyl Citrate 10. Furosemide 11.\n Haloperidol 12. Heparin 13. Insulin 14. Magnesium Oxide\n 15. Magnesium Sulfate 16. Metoprolol Tartrate 17. Morphine Sulfate 18.\n Neutra-Phos 19. Norepinephrine 20. Piperacillin-Tazobactam 22.\n Vancomycin\n 24 Hour Events:\n CHEST TUBE PLACED - At 05:42 PM\n ARTERIAL LINE - START 06:30 PM\n EKG - At 02:15 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 07:51 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:45 PM\n Heparin Sodium (Prophylaxis) - 12:28 AM\n Metoprolol - 02:15 AM\n Diltiazem - 03:47 AM\n Furosemide (Lasix) - 03:47 AM\n Other medications:\n Flowsheet Data as of 04:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.1\nC (98.8\n HR: 128 (76 - 134) bpm\n BP: 93/50(63) {93/41(59) - 136/56(83)} mmHg\n RR: 26 (22 - 33) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 5,035 mL\n 469 mL\n PO:\n Tube feeding:\n IV Fluid:\n 785 mL\n 469 mL\n Blood products:\n Total out:\n 448 mL\n 104 mL\n Urine:\n 198 mL\n 104 mL\n NG:\n Stool:\n Drains:\n 250 mL\n Balance:\n 4,587 mL\n 365 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: 7.39/30/103/19/-5\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 634 K/uL\n 10.3 g/dL\n 80 mg/dL\n 0.5 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 11 mg/dL\n 114 mEq/L\n 142 mEq/L\n 30.8 %\n 35.8 K/uL\n [image002.jpg]\n 06:21 PM\n 01:13 AM\n 03:46 AM\n WBC\n 48.3\n 35.8\n Hct\n 36.0\n 30.8\n Plt\n 821\n 634\n Creatinine\n 0.5\n 0.5\n Troponin T\n <0.01\n TCO2\n 19\n Glucose\n 84\n 92\n 80\n Other labs: PT / PTT / INR:17.6/49.6/1.6, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Ca:7.1 mg/dL, Mg:1.5 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neuro: alert, haldol for agitation, morphine for pain\n CVS: Afib O/N, hypotension w/ metoprolol, amiodarone started, repeat\n EKG, CE's, TSH P\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc/Zosyn,\n pleural fluid cx sent, on NC, IR to drain remaining abscesses \n GI: bowel regimen, home PPI\n FEN: LR 100, NPO x meds, replete lytes\n Renal: euvolemic, u/o 30-100, LOS +5L\n Heme: stable Hct 42.8, on SCH, INR 1.1\n Endo: RISS\n ID: Febrile, WC 36.5, w/ LS, Vanco / Zosyn\n TLD: A-line, PIVx2\n Wounds: none\n Imaging: CXR P\n Prophylaxis: SCH, boots, PPI\n Consults: thoracic\n Code: FULL\n Disposition: SICU\n Billing Diagnosis:\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:38 PM\n Arterial Line - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 37 minutes\n" }, { "category": "Nursing", "chartdate": "2190-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382623, "text": "89 y.o. F with CAD s/p MI, atrial fibrillation (not on\n anticoagulation), frequent falls, and CHF (EF >65% ) who\n presented to the ED on with RUQ and R chest pain that was\n severe for patient at 7 AM on .\n Delirium / confusion\n Assessment:\n Pt agitated, attempting to get OOB. + hallucinations. Uncooperative\n with care. Oriented to person only, at times completely disoriented.\n Picking at tubes and lines.\n Action:\n 0.5 mg haldol IV given as ordered with minimal response. 5-10mg zyprexa\n disintegrating tablet po given as ordered.\n Response:\n Pt calm, cooperative with care.\n Plan:\n Continue\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2190-07-02 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 382717, "text": "Subjective\n confused, not taking pos.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 57 kg\n 59.1 kg ( 11:00 AM)\n 20.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 100\n Diagnosis: EMPYEMA\n PMH :\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Pertinent medications: Insulin SC , Heparin, Docusate Sodium,\n Piperacillin-Tazobactam, IV Sliding Scale ( Magnesium Sulfate, Calcium\n Gluconate, Sodium Phosphate, Potassium Chloride), Vancomycin, others\n noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 02:06 AM\n Glucose Finger Stick\n 111\n 10:00 PM\n BUN\n 16 mg/dL\n 02:06 AM\n Creatinine\n 0.6 mg/dL\n 02:06 AM\n Sodium\n 144 mEq/L\n 02:06 AM\n Potassium\n 3.6 mEq/L\n 02:06 AM\n Chloride\n 113 mEq/L\n 02:06 AM\n TCO2\n 20 mEq/L\n 02:06 AM\n PO2 (arterial)\n 90. mm Hg\n 07:53 AM\n PCO2 (arterial)\n 30 mm Hg\n 07:53 AM\n pH (arterial)\n 7.43 units\n 07:53 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 07:53 AM\n Albumin\n 2.0 g/dL\n 07:39 AM\n Calcium non-ionized\n 7.9 mg/dL\n 02:06 AM\n Phosphorus\n 2.9 mg/dL\n 02:06 AM\n Ionized Calcium\n 1.21 mmol/L\n 07:53 AM\n Magnesium\n 2.0 mg/dL\n 02:06 AM\n WBC\n 29.4 K/uL\n 02:06 AM\n Hgb\n 9.8 g/dL\n 02:06 AM\n Hematocrit\n 30.3 %\n 02:06 AM\n Current diet order / nutrition support: Regular; Cardiac/Heart healthy\n Consistency: Ground (dysphagia); Thin liquids [Started at: Clear\n liquids, Advance as tolerated to: Regular]\n GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: age\n Estimated Nutritional Needs\n Calories: 1425-1596 (BEE x or / 25-28 cal/kg)\n Protein: 68-78 (1.2-1.4 g/kg)\n Fluid: per team\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n 89 year old woman admitted on with right flank pain. CT\n showing right sided loculated pleural effusion, (likely empyema), s/p\n pigtail placement. Patient passed speech and swallow evaluation, okay\n to take ground diet with thin liquid, yet patient is currently refusing\n pos. consider tube feed as temporary nutrition support if it\n consisted with goal of care.\n Medical Nutrition Therapy Plan - Recommend the Following\n Ensure plus as po supplement if patient agree to it\n Multivitamin / Mineral supplement: daily\n Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr (\n 1620kcal/73g protein)\n Check chemistry 10 panel daily, replete per sliding scale\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Other: \n" }, { "category": "Nursing", "chartdate": "2190-07-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383011, "text": "F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Respiratory failure, chronic\n Assessment:\n Patient continues to have pigtail chest tube in place to dry suction\n draining 50 cc serosanguinous fluid. Lungs sound diminished on right\n side, clear on left side. On 5 L NC. O2 sats 96-100%.\n Action:\n Continues on antibiotics however vanco discontinued,\n Patient encouraged to cough and deep breathe frequently, chest PT,\n OOB to chair,\n O2 weaned to 3 L NC.\n Response:\n O2 sats continue to be 96-100%, Patient denies SOB.\n Plan:\n Continue to monitor, transfer to 9 awaiting available bed, rehab?\n Delirium / confusion\n Assessment:\n Patient oriented x , although confused at times. Able to take po\n however coughing frequently.\n Action:\n - reoriented frequently,\n - speech and swallow called for a reevaluation.\n Response:\n Patient calm and easily reoriented,\n Patient did well with speech and swallow eval, able to have soft solids\n and thin liquids.\n Plan:\n Continue to monitor, reorient as needed.\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382488, "text": "Delirium / confusion\n Assessment:\n Pt was alert and oriented at the beginning of the shift with some mild\n intermittent confusion noted. At midnight, pt woke from sleep and\n became slightly combative, confused and refused care.\n Action:\n Dr. notified, pt monitored closely for safety and approached\n several times for reevaluation.\n Response:\n Confusion lessening at 2 am when waking pt, became pleasant and\n cooperative.\n Plan:\n Continue to monitor mental status, orient when necessary, provide\n emotional support\n Sepsis without organ dysfunction\n Assessment:\n BP stable at beginning of the shift, remained 100-130 systolic most of\n the night while in sinus rhythm. UOP minimal, 20-30 cc/hr. WBCs\n trending down this am. Tmax 99 axillary, pt not cooperating for oral\n temp.\n Action:\n Levo weaned down and stopped at beginning of the shift. Many\n conversations had with SICU and Thoracic team regarding Lasix vs.\n fluid. Decision made for small fluid bolus and if UOP decreases below\n 20cc/hr, lasix to be ordered. Zosyn and Vanco started.\n Response:\n Sepsis resolving\n Plan:\n Continue to monitor white count, temp, BP and need for pressors.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o lower ext pain that she states is not new. Also c/o intermittent\n pain in right upper back area consistent with area of chest tube\n Action:\n Repositioned frequently, Morphine 2mg and Tylenol given\n Response:\n Pt responding best to Tylenol, Morphine not lasting long enough.\n Plan:\n Continue to offer pain relief with po, iv meds and repostioning\n Atrial fibrillation (Afib)\n Assessment:\n Pt converting to rapid a-fib this am, rate 120-150. BP stable at that\n time.\n Action:\n Lopressor 5mg given x 1, EKG done, labs sent. When Lopressor not\n effective, Diltiazem 5 mg given x 1, Lasix 10mg, chest x-ray.\n Response:\n Primary team deciding not to use Dilt gtt, changed to Amio gtt\n following 150mg bolus. Rate is now decreased to 100-120, however\n remaining in a-fib. BP decreasing to high 80\ns systolic following\n Lopressor dose.\n Plan:\n Continue to monitor HR, continue Amio gtt.\n Respiratory failure, chronic\n Assessment:\n Pt having resp distress this am, tachypneic and having labored\n breathing. Lungs rhoncherous with exp. Wheezing. Coughing and raising\n small amounts of thick whitish sputum.\n Action:\n Resident notified. Lasix 10mg given x 2. Resp therapist paged and in to\n eval. ABG pending, Bipap ordered\n Response:\n Pt responding to second dose of Lasix, however team may order more.\n Plan:\n Continue to monitor resp status, offer emotional support\n" }, { "category": "Nursing", "chartdate": "2190-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382620, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382811, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases.\n Slightly dyspneic when getting OOB, difficulty recovering\n O2 sat 97-100% on 4 L nc\n Chest tube dry suction draining large amts serosang drainage\n Action:\n Albuterol nebs prn\n OOB to chair most of shift\n Response:\n Pt comfortable, no further episodes SOB\n Plan:\n Continue to monitor CT output\n nebs prn\n OOB to chair as tolerated\n" }, { "category": "Nursing", "chartdate": "2190-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382812, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases.\n Slightly dyspneic when getting OOB, difficulty recovering\n O2 sat 97-100% on 4 L nc\n Chest tube dry suction draining large amts serosang drainage\n Action:\n Albuterol nebs prn\n OOB to chair most of shift\n Response:\n Pt comfortable, no further episodes SOB\n Plan:\n Continue to monitor CT output\n nebs prn\n OOB to chair as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with acute and chronic back pain, worse with turning\n Action:\n Tylenol given\n Lidocaine patch applied\n OOB to chair\n Response:\n Denies pain\n Plan:\n Cont med regimen, activity\n" }, { "category": "Nursing", "chartdate": "2190-07-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382933, "text": "Respiratory failure, chronic\n Assessment:\n Pt continues with slight resp distress. Currently remains with chest\n tube drain in place for empyema draining serosanguinous fluid. Resp\n status unchanged from previous shift, LS essentially clear, dim to\n bases, good SpO2 on 4l NC.\n Pt remains confused at times, very forgetful.\n Action:\n Encouraged cough and deep breathing.\n Response:\n Unchanged exam\n Plan:\n Drain may be removed by team today, pt to TX to floor.\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382471, "text": "Delirium / confusion\n Assessment:\n Pt was alert and oriented at the beginning of the shift with some mild\n intermittent confusion noted. At midnight, pt woke from sleep and\n became slightly combative, confused and refused care.\n Action:\n Dr. notified, pt monitored closely for safety and approached\n several times for reevaluation.\n Response:\n Confusion lessening at 2 am when waking pt, pleasant and cooperative\n Plan:\n Continue to monitor mental status, orient when necessary, provide\n emotional support\n Sepsis without organ dysfunction\n Assessment:\n BP stable at beginning of the shift, remained 100-130 systolic most of\n the night while in sinus rhythm. UOP minimal, 20-30 cc/hr. WBCs\n trending down this am. Tmax 99 axillary, pt not cooperating for oral\n temp.\n Action:\n Levo weaned down and stopped at beginning of the shift. Many\n conversations had with SICU and Thoracic team regarding Lasix vs.\n fluid. Decision made for small fluid bolus and if UOP decreases below\n 20cc/hr, lasix to be ordered. Zosyn and Vanco started.\n Response:\n Sepsis resolving\n Plan:\n Continue to monitor white count, temp, BP and need for pressors.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o lower ext pain that she states is not new. Also c/o intermittent\n pain in right upper back area consistent with area of chest tube\n Action:\n Repositioned frequently, Morphine 2mg and Tylenol given\n Response:\n Pt responding best to Tylenol, Morphine not lasting long enough.\n Plan:\n Continue to offer pain relief with po, iv meds and repostioning\n Atrial fibrillation (Afib)\n Assessment:\n Pt converting to rapid a-fib this am, rate 120-150. BP stable at that\n time.\n Action:\n Lopressor 5mg given x 1, EKG done, labs sent. When Lopressor not\n effective, Diltiazem 5 mg given x 1, Lasix 10mg, chest x-ray.\n Response:\n Primary team deciding not to use Dilt gtt, changed to Amio gtt\n following 150mg bolus. Rate is now decreased to 100-120, however\n remaining in a-fib. BP decreasing to high 80\ns systolic following\n Lopressor dose.\n Plan:\n Continue to monitor HR, continue Amio gtt.\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382476, "text": "Delirium / confusion\n Assessment:\n Pt was alert and oriented at the beginning of the shift with some mild\n intermittent confusion noted. At midnight, pt woke from sleep and\n became slightly combative, confused and refused care.\n Action:\n Dr. notified, pt monitored closely for safety and approached\n several times for reevaluation.\n Response:\n Confusion lessening at 2 am when waking pt, became pleasant and\n cooperative.\n Plan:\n Continue to monitor mental status, orient when necessary, provide\n emotional support\n Sepsis without organ dysfunction\n Assessment:\n BP stable at beginning of the shift, remained 100-130 systolic most of\n the night while in sinus rhythm. UOP minimal, 20-30 cc/hr. WBCs\n trending down this am. Tmax 99 axillary, pt not cooperating for oral\n temp.\n Action:\n Levo weaned down and stopped at beginning of the shift. Many\n conversations had with SICU and Thoracic team regarding Lasix vs.\n fluid. Decision made for small fluid bolus and if UOP decreases below\n 20cc/hr, lasix to be ordered. Zosyn and Vanco started.\n Response:\n Sepsis resolving\n Plan:\n Continue to monitor white count, temp, BP and need for pressors.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o lower ext pain that she states is not new. Also c/o intermittent\n pain in right upper back area consistent with area of chest tube\n Action:\n Repositioned frequently, Morphine 2mg and Tylenol given\n Response:\n Pt responding best to Tylenol, Morphine not lasting long enough.\n Plan:\n Continue to offer pain relief with po, iv meds and repostioning\n Atrial fibrillation (Afib)\n Assessment:\n Pt converting to rapid a-fib this am, rate 120-150. BP stable at that\n time.\n Action:\n Lopressor 5mg given x 1, EKG done, labs sent. When Lopressor not\n effective, Diltiazem 5 mg given x 1, Lasix 10mg, chest x-ray.\n Response:\n Primary team deciding not to use Dilt gtt, changed to Amio gtt\n following 150mg bolus. Rate is now decreased to 100-120, however\n remaining in a-fib. BP decreasing to high 80\ns systolic following\n Lopressor dose.\n Plan:\n Continue to monitor HR, continue Amio gtt.\n" }, { "category": "Physician ", "chartdate": "2190-07-03 00:00:00.000", "description": "Intensivist Note", "row_id": 382782, "text": "SICU\n HPI:\n F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n Empyema\n PMHx:\n PMH: Frequent Falls , CAD - s/p MI years ago , CHF - ? last ECHO\n EF 70% , Atrial fibrillation ,\n Chronic venous stasis with b/l lower extremity edema , Constipation,\n Degenerative disc disease followed by ortho\n PSH:Hernia repair, appy\n Current medications:\n 1. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Alteplase 6.\n Amiodarone 7. Atorvastatin 8. Calcium Gluconate 9. Docusate Sodium 10.\n Furosemide 11. Heparin 12. Insulin 13. Lansoprazole Oral Disintegrating\n Tab 14. Lidocaine 5% Patch 17. Metoprolol Tartrate 18. Morphine Sulfate\n 19. Piperacillin-Tazobactam 20. Potassium Chloride 21. Quetiapine\n Fumarate 22. Senna 25. Tiotropium Bromide 26. Vancomycin 27.\n Venlafaxine\n 24 Hour Events:\n : TPA (again). Blown pupil w/ lethargy. Head CT obtained. Waiting\n optho consult. Improved mental status.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:53 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 59 (57 - 73) bpm\n BP: 96/40(54) {90/39(53) - 162/90(101)} mmHg\n RR: 20 (14 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SVT (Supra Ventricular Tachycardia)\n Wgt (current): 59.1 kg (admission): 57 kg\n Height: 65 Inch\n CVP: 1 (0 - 11) mmHg\n Total In:\n 890 mL\n 151 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 790 mL\n 151 mL\n Blood products:\n Total out:\n 850 mL\n 55 mL\n Urine:\n 440 mL\n 55 mL\n NG:\n Stool:\n Drains:\n 410 mL\n Balance:\n 40 mL\n 96 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: Left pupil dilated, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), (Distant heart\n sounds: Absent)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Wheezes : ,\n Rhonchorous : , Diminished: Bases bilaterally)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities, Not oriented. Waxing/ exam t/o day\n Labs / Radiology\n 700 K/uL\n 9.4 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.2 mEq/L\n 17 mg/dL\n 113 mEq/L\n 145 mEq/L\n 29.7 %\n 21.2 K/uL\n [image002.jpg]\n 01:13 AM\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n 03:21 AM\n WBC\n 35.8\n 27.0\n 29.4\n 21.2\n Hct\n 30.8\n 31.6\n 30.3\n 29.7\n Plt\n 634\n 649\n 665\n 700\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n 0.5\n TCO2\n 19\n 17\n 21\n Glucose\n 92\n 80\n 94\n 140\n 102\n 101\n 116\n 107\n Other labs: PT / PTT / INR:16.3/44.5/1.4, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL, LDH:208 IU/L,\n Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, RESPIRATORY FAILURE,\n CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neurologic: Alert, seroquel for agitation /insomnia, morphine for pain.\n Dilated L pupil. Normal head CT. Optho consulted\n Cardiovascular: Afib, on amiodarone PO and metoprolol (QT: 0.424)\n Pulmonary: Empyema from PNA, s/p pigtail placement by IP, on\n Vanc/Zosyn, pleural fluid cx sent, no further intervention on apical\n effusion per thoracics, TPA given via pigtail , \n Gastrointestinal / Abdomen: Bowel regimen, home PPI\n Nutrition: Speech and Swallow eval, Confused. Taking minimal PO.\n Encourage oral intake\n Renal: Foley, Marginal UOP. On home lasix.\n Hematology: on SCH for proph\n Endocrine: RISS\n Infectious Disease: Vanc / Zosyn for loculated pleural effusions, check\n trough\n Lines / Tubes / Drains: foley, RSC CVL, CT pigtail\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, Neurology, Geriatrics\n Billing Diagnosis: Arrhythmia, (Pneumonia due to procedure)\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382918, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases.\n O2 sat 97-100% on 4 L nc\n Chest tube dry suction draining large amts serosang drainage\n Action:\n OOB to chair\n encouraged to cough/ deep breaths\n Response:\n Pt comfortable\n Resp status continues to improve\n Plan:\n Continue to monitor CT output\n nebs prn\n wean O2 as tolerated\n OOB to chair as tolerated\n transfer to floor in am, to rehab this week per Dr. \n" }, { "category": "Physician ", "chartdate": "2190-07-04 00:00:00.000", "description": "Intensivist Note", "row_id": 382843, "text": "SICU\n HPI:\n F w/ loculated pleural effusion s/p pigtail placement now in Afib\n Chief complaint:\n empyema\n PMHx:\n PMH: Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n PSH:Hernia repair, appy\n Current medications:\n 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Amiodarone 6.\n Atorvastatin 7. Calcium Gluconate\n 8. Docusate Sodium 9. Furosemide 10. Heparin 11. Insulin 12.\n Lansoprazole Oral Disintegrating Tab\n 13. Lidocaine 5% Patch 14. Magnesium Sulfate 15. Magnesium Sulfate 16.\n Metoprolol Tartrate 17. Morphine Sulfate\n 18. Piperacillin-Tazobactam 19. Potassium Chloride 20. Quetiapine\n Fumarate 21. Senna 22. Sodium Chloride 0.9% Flush\n 23. Sodium Phosphate 24. Tiotropium Bromide 25. Vancomycin 26.\n Venlafaxine\n 24 Hour Events:\n EKG - At 02:04 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:35 AM\n Piperacillin/Tazobactam (Zosyn) - 11:56 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Furosemide (Lasix) - 12:30 AM\n Other medications:\n Flowsheet Data as of 04:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 64 (58 - 84) bpm\n BP: 124/84(95) {90/34(48) - 124/84(95)} mmHg\n RR: 20 (18 - 29) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.1 kg (admission): 57 kg\n Height: 65 Inch\n CVP: 0 (0 - 6) mmHg\n Total In:\n 900 mL\n 148 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 840 mL\n 148 mL\n Blood products:\n Total out:\n 955 mL\n 513 mL\n Urine:\n 495 mL\n 363 mL\n NG:\n Stool:\n Drains:\n 180 mL\n 150 mL\n Balance:\n -55 mL\n -365 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 802 K/uL\n 10.2 g/dL\n 109 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 16 mg/dL\n 113 mEq/L\n 144 mEq/L\n 30.7 %\n 26.2 K/uL\n [image002.jpg]\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n 03:21 AM\n 02:05 AM\n WBC\n 27.0\n 29.4\n 21.2\n 26.2\n Hct\n 31.6\n 30.3\n 29.7\n 30.7\n Plt\n 02\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n 0.5\n 0.5\n TCO2\n 19\n 17\n 21\n Glucose\n 80\n 94\n 140\n 102\n 101\n 116\n 107\n 109\n Other labs: PT / PTT / INR:15.0/41.0/1.3, CK / CK-MB / Troponin\n T:23//<0.01, Differential-Neuts:81.0 %, Band:1.0 %, Lymph:8.0 %,\n Mono:5.0 %, Eos:3.0 %, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL,\n LDH:208 IU/L, Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n BRADYCARDIA, PROBLEM - ENTER DESCRIPTION IN COMMENTS, RESPIRATORY\n FAILURE, CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE PAIN,\n CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 90 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neuro: alert, seroquel for agitation /insomnia, morphine for pain.\n CVS: Afib, on amiodarone PO and metoprolol (QT: 0.424)\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc/Zosyn,\n pleural fluid cx sent, no further intervention on apical effusion per\n thoracics, TPA given via pigtail , \n GI: bowel regimen, home PPI\n FEN: Regular diet, KVO. On home lasix. Repleting electrolytes\n Renal: euvolemic, UOP 13-140, on home lasix.\n Heme: on SCH for proph\n Endo: RISS\n ID: Vanc/Zosyn for loculated pleural effusions, check trough \n TLD: foley, RSC CVL, CT pigtail\n Wounds: none\n Imaging:\n Prophylaxis: SCH, boots, PPI\n Consults: thoracic, ID, geriatrics, neuromed\n Code: FULL\n Disposition: transfer to floor\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382451, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382842, "text": "Delirium / confusion\n Assessment:\n Pt sleeping intermittently throughout the night, arousable to voice.\n Oriented to\n and person only. Can answer simple questions\n appropriately. Pupils equal, left appearing sluggish but reactive. No\n delirium noted this shift, pt is pleasant and only mildly confused at\n times. Moving all ext on the bed, following all commands.\n Action:\n Neuro assessment Q 4 hours. Reoriented at needed. Pt in calm quiet\n atmosphere\n Response:\n Pt resting comfortably throughout the shift\n Plan:\n Continue to monitor neuro status, reorient and offer emotional support\n as needed\n Problem - Description In Comments\n Assessment:\n Low UOP, 10-20cc for a few hours overnight. Pt\ns fluid balance even at\n midnight. CVP 1-2\n Action:\n Dr. notified, Lasix 10mg given IV x 1\n Response:\n Urine output improving, averaging 80-100cc/hr\n Plan:\n Continue to monitor uop and assess need for additional Lasix\n Bradycardia\n Assessment:\n HR decreasing to 30\ns at times, pt sleeping. BP stable.\n Action:\n Resident paged, EKG done, labs sent, Atropine at the bedside.\n Response:\n Pt asymptomatic.\n Plan:\n Continue to monitor HR, labs, atropine at the bedside\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 382905, "text": " yo female with hx CAD, CHF, A fib (not on anticoagulation), chronic\n venous stasis, orthostatic hypotension, trigeminal herpes zoster ,\n degenerative disc disease (resulting in chronic back pain issues). She\n presented to the ED on with right chest and RUQ pain. In ED\n she was febrile to 101.4 and hypotensive 85/41. Chest CT revealed RUL\n and RLL pleural effusions and empyema. Transferred to SICU for further\n management. Thoracentesis performed on arrival. Pigtail drain placed.\n" }, { "category": "Rehab Services", "chartdate": "2190-07-05 00:00:00.000", "description": "Repeat Bedside Swallowing Evaluation", "row_id": 382994, "text": "TITLE: REPEAT BEDSIDE SWALLOWING EVALUATION\n INTERIM HISTORY\n Thank you for paging on this year old woman admitted on with\n R empyema s/p pigtail placement. We initially met the pt on at\n which time she was confused and agitated with poor participation in\n formal evaluation. Based on limited info, we recommended diet order of\n ground solids and thin liquids with PO meds crushed in puree. Pt was\n initially refusing all PO, but today's RN, she is much calmer and\n over the last few days has begun taking small volumes at meals. Has\n had some concerns for dehydration and MD team is encouraging clear\n liquids. RN noted coughing with water this morning and requested\n re-evaluation.\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the bed on SICU B.\n Cognition, language, speech, voice:\n Awake, alert, oriented to self only. Follows simple commands. Answers\n personal questions appropriately. Engages easily in conversation.\n Language fluent. Speech WNL. Voice slightly gravelly.\n Teeth: fair condition on bottom, upper dentures in place on top\n Secretions: grossly WNL in oral cavity\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Tongue protrudes midline with adequate\n strength and ROM. Labial seal intact. Palatal elevation adequate.\n Gag deferred.\n SWALLOWING ASSESSMENT:\n Pt offered ice chips, thin liquid (tspn, straw, consecutive), puree,\n and bites of cracker. Oral phase notable for mildly prolonged\n mastication, difficulty taking isolated bite from cracker, and\n talking with food in mouth. Required liquid wash down to clear mild\n oral cavity residue of cracker. Laryngeal elevation adequate to\n palpation. No throat clearing, coughing, choking, O2 desat (stable at\n 98%) or vocal quality changes during or after PO intake. Pt denied\n sensation of aspiration, pharyngeal residue, or odynophagia.\n SUMMARY / IMPRESSION:\n Pt presents without signs or symptoms of aspiration at bedside. While\n silent aspiration cannot be ruled out without videoswallow study, her\n attention, coordination, and stable respiratory status during today's\n evaluation reduce the likelihood for silent aspiration. Pt appears\n safe for diet upgrade to soft solids and thin liquids, which may\n improve her volume of intake slightly, as it is a more appealing diet\n order. She should continue 1:1 supervision with meals to maintain\n aspiration precautions and encourage increased PO intake. Please feel\n free to reconsult if we can be of further assistance.\n This swallowing pattern correlates to a Dysphagia Outcome Severity\n Scale (DOSS) rating of 5, mild dysphagia.\n RECOMMENDATIONS:\n 1. PO diet: soft solids, thin liquids\n 2. PO meds crushed in puree or ice cream\n 3. TID oral care\n 4. 1:1 assist with PO to encourage intake and maintain standard\n aspiration precautions.\n 5. Nutrition f/u\n 6. Please page/reconsult if we can be of further assistance.\n These recommendations were shared with the patient, nurse and medical\n team.\n M.S., CCC-SLP\n Pager # \n Face time: 15:15-15:30\n Total time: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2190-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 382558, "text": "SICU\n HPI:\n 89F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Current medications:\n . 2. 3. Acetaminophen 4. Amiodarone 5. Amiodarone 6. Atorvastatin 7.\n Calcium Gluconate 8. Docusate Sodium\n 9. Haloperidol 10. Heparin 11. Insulin 12. Lansoprazole Oral\n Disintegrating Tab 13. Lidocaine 5% Patch\n 14. Magnesium Sulfate 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Morphine Sulfate 18. Norepinephrine\n 19. Piperacillin-Tazobactam 20. Potassium Chloride 21. Senna 22. Sodium\n Chloride 0.9% Flush 23. Sodium Phosphate\n 24. Vancomycin\n 24 Hour Events:\n MULTI LUMEN - START 08:00 AM\n TRANSTHORACIC ECHO - At 10:50 AM\n EKG - At 12:57 PM\n ULTRASOUND - At 04:30 PM\n Haldol for agitation, pulled foley out. IP did not place a second\n pigtail in apical collection\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Furosemide (Lasix) - 06:10 AM\n Famotidine (Pepcid) - 08:58 AM\n Heparin Sodium (Prophylaxis) - 01:54 AM\n Other medications:\n Flowsheet Data as of 04:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.3\nC (97.4\n HR: 80 (60 - 119) bpm\n BP: 152/74(105) {73/40(55) - 158/100(108)} mmHg\n RR: 18 (18 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58 kg (admission): 57 kg\n CVP: 8 (4 - 12) mmHg\n Total In:\n 1,892 mL\n 154 mL\n PO:\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,532 mL\n 154 mL\n Blood products:\n Total out:\n 980 mL\n 125 mL\n Urine:\n 800 mL\n 125 mL\n NG:\n Stool:\n Drains:\n 180 mL\n Balance:\n 912 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: 7.43/30/90./20/-2\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: No(t) Rash:\n Neurologic: (Awake / Alert / Oriented: x 2, x 1), Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 649 K/uL\n 10.7 g/dL\n 102 mg/dL\n 0.5 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 114 mEq/L\n 143 mEq/L\n 31.6 %\n 27.0 K/uL\n [image002.jpg]\n 06:21 PM\n 01:13 AM\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n WBC\n 48.3\n 35.8\n 27.0\n Hct\n 36.0\n 30.8\n 31.6\n Plt\n 821\n 634\n 649\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n Troponin T\n <0.01\n TCO2\n 19\n 17\n 21\n Glucose\n 84\n 92\n 80\n 94\n 140\n 102\n Other labs: PT / PTT / INR:17.6/49.6/1.6, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL, LDH:208 IU/L,\n Ca:8.2 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC, ATRIAL FIBRILLATION (AFIB), DELIRIUM /\n CONFUSION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), SEPSIS WITHOUT\n ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neuro: alert, haldol for agitation, morphine for pain\n CVS: Afib O/N, levo restarted for hypotension, amiodarone started\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc/Zosyn,\n pleural fluid cx sent, on NC\n GI: bowel regimen, home PPI\n FEN: KVO, reg diet\n Renal: Borderline UOP 10+cc/hr\n Heme: on SCH for proph\n Endo: RISS\n ID: Febrile, WC 36.5, w/ LS, Vanc/Zosyn, check trough AM \n TLD: Aline, PIVx2, TLC , pigtail, CVL, pigtail\n Wounds: none\n Imaging: CXR P\n Prophylaxis: SCH, boots, PPI\n Consults: thoracic\n Code: FULL\n Disposition: SICU\n Consults: Pulmonology, Geriatrics, Thoracic Surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:30 PM\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2190-07-02 00:00:00.000", "description": "Intensivist Note", "row_id": 382653, "text": "SICU\n HPI:\n F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n flank pain\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 4. Acetaminophen 5.\n Alteplase 6. Albuterol 0.083% Neb Soln\n 7. Amiodarone 8. Atorvastatin 9. Calcium Gluconate 10. Docusate Sodium\n 11. Furosemide 12. Heparin\n 13. Insulin 14. Lansoprazole Oral Disintegrating Tab 15. Lidocaine 5%\n Patch 16. Magnesium Sulfate\n 17. Magnesium Sulfate 18. Metoprolol Tartrate 19. Metoprolol Tartrate\n 20. Morphine Sulfate 21. Norepinephrine\n 22. Piperacillin-Tazobactam 23. Potassium Chloride 24. Quetiapine\n Fumarate 25. Senna 26. Sodium Chloride 0.9% Flush\n 27. Sodium Phosphate 28. Tiotropium Bromide 29. Vancomycin 30.\n Venlafaxine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:20 AM\n EKG - At 11:45 AM\n tpa to chest tube, had desat episode w/ tachypnea, got\n albuterol+atrovent + lasix, later developed fixed and dilated left\n pupil, got neuro consult\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:26 AM\n Furosemide (Lasix) - 04:01 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.7\nC (98\n HR: 71 (65 - 104) bpm\n BP: 114/44(62) {97/38(56) - 149/110(116)} mmHg\n RR: 20 (18 - 31) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.1 kg (admission): 57 kg\n CVP: 3 (2 - 9) mmHg\n Total In:\n 881 mL\n 142 mL\n PO:\n Tube feeding:\n IV Fluid:\n 881 mL\n 142 mL\n Blood products:\n Total out:\n 981 mL\n 90 mL\n Urine:\n 871 mL\n 90 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -100 mL\n 52 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///20/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), No(t) Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), Moves all\n extremities, pt is confused, does not follow commands\n Labs / Radiology\n 665 K/uL\n 9.8 g/dL\n 116 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 16 mg/dL\n 113 mEq/L\n 144 mEq/L\n 30.3 %\n 29.4 K/uL\n [image002.jpg]\n 06:21 PM\n 01:13 AM\n 03:46 AM\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n WBC\n 48.3\n 35.8\n 27.0\n 29.4\n Hct\n 36.0\n 30.8\n 31.6\n 30.3\n Plt\n 821\n 634\n 649\n 665\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n Troponin T\n <0.01\n TCO2\n 19\n 17\n 21\n Glucose\n 84\n 92\n 80\n 94\n 140\n 102\n 101\n 116\n Other labs: PT / PTT / INR:16.3/44.5/1.4, CK / CK-MB / Troponin\n T:23//<0.01, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL, LDH:208 IU/L,\n Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 89 F w/ loculated pleural effusion s/p pigtail\n placement now in Afib\n Neurologic: alert, seroquel for agitation /insomnia x1 ordered,\n morphine for pain\n Cardiovascular: Afib O/N, off levo, amiodarone PO started, metoprolol\n started () (QT: 0.424)\n Pulmonary: empyema from PNA, s/p pigtail placement by IP, on\n Vanc/Zosyn, pleural fluid cx sent, no further intervention on apical\n effusion per thoracics, TPA given via pigtail , episode of desat\n and tachypnea yesterday afternoon responding to nebs + lasix\n Gastrointestinal / Abdomen: bowel regimen, home PPI\n Nutrition: confused and not taking PO, KVO for now d/t concerns of vol\n overload,\n Renal: Marginal UOP but repsonded to lasix\n Hematology: on SCH for proph\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn for loculated pleural effusions, check\n trough AM , f/u cx\n Lines / Tubes / Drains: foley, RSC CVL, pigtail\n Wounds:\n Imaging:\n Fluids:\n Consults: thoracic, ID, thoracics\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments: SCH, boots, PPI\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2190-07-05 00:00:00.000", "description": "Intensivist Note", "row_id": 382972, "text": "SICU\n HPI:\n F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Atorvastatin 6.\n Calcium Gluconate 7. Docusate Sodium\n 8. Furosemide 9. Heparin 10. Insulin 11. Lansoprazole Oral\n Disintegrating Tab 12. Lidocaine 5% Patch\n 13. Magnesium Sulfate 14. Magnesium Sulfate 15. Metoprolol Tartrate 16.\n Morphine Sulfate 17. Piperacillin-Tazobactam\n 18. Potassium Chloride 19. Quetiapine Fumarate 20. Senna 21. Sodium\n Chloride 0.9% Flush 22. Sodium Phosphate\n 23. Tiotropium Bromide 24. Vancomycin 25. Venlafaxine\n 24 Hour Events:\n Pleural fluid growing strep, amiodarone d/cd, stable, eating ground\n diet, no new issues\n Post operative day:\n POD 6 s/p thoracic pigtail drain placement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:10 PM\n Other medications:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 61 (60 - 71) bpm\n BP: 107/40(56) {90/30(47) - 124/76(80)} mmHg\n RR: 19 (17 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.1 kg (admission): 57 kg\n Height: 65 Inch\n CVP: 2 (0 - 12) mmHg\n Total In:\n 1,470 mL\n 255 mL\n PO:\n 180 mL\n Tube feeding:\n 200 mL\n 100 mL\n IV Fluid:\n 1,090 mL\n 155 mL\n Blood products:\n Total out:\n 1,038 mL\n 120 mL\n Urine:\n 778 mL\n 120 mL\n NG:\n Stool:\n Drains:\n 150 mL\n Balance:\n 432 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Skin: Rash:\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 712 K/uL\n 8.3 g/dL\n 94 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 141 mEq/L\n 26.7 %\n 19.4 K/uL\n [image002.jpg]\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n 03:21 AM\n 02:05 AM\n 02:04 AM\n WBC\n 27.0\n 29.4\n 21.2\n 26.2\n 19.4\n Hct\n 31.6\n 30.3\n 29.7\n 30.7\n 26.7\n Plt\n 02\n 712\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 17\n 21\n Glucose\n 94\n 140\n 102\n 101\n 116\n 107\n 109\n 94\n Other labs: PT / PTT / INR:14.0/50.2/1.2, CK / CK-MB / Troponin\n T:23//<0.01, Differential-Neuts:81.0 %, Band:1.0 %, Lymph:8.0 %,\n Mono:5.0 %, Eos:3.0 %, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL,\n LDH:208 IU/L, Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n BRADYCARDIA, PROBLEM - ENTER DESCRIPTION IN COMMENTS, RESPIRATORY\n FAILURE, CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE PAIN,\n CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 90 F w/ loculated pleural effusion s/p pigtail\n placement complicated by Afib, now in sinus rhythm\n Neuro: alert, seroquel for agitation /insomnia prn, morphine for pain.\n CVS: Afib controlled on metoprolol, now in sinus\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc/Zosyn,\n pleural fluid cx sent, no further intervention on apical effusion per\n thoracics, TPA given via pigtail , , cx with sparse growth of\n Streptococcus\n GI: bowel regimen, home PPI\n FEN: Regular diet, KVO. On home lasix. Repleting electrolytes\n Renal: Stable UOP, on home lasix.\n Heme: on SCH for proph\n Endo: RISS\n ID: Zosyn for loculated pleural effusions, pleural fluid growing\n Streptococcus\n TLD: foley, RSC CVL, CT pigtail d/c cvl\n Wounds: none\n Imaging: CXR\n Consults: Neurology, ID dept, Thoracic Surgery, Geriatrics\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure),\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines: foley, RSC CVL, CT pigtail\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n consent signed:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: Time spent 32 min\n" }, { "category": "Nursing", "chartdate": "2190-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382635, "text": "89 y.o. F with CAD s/p MI, atrial fibrillation (not on\n anticoagulation), frequent falls, and CHF (EF >65% ) who\n presented to the ED on with RUQ and R chest pain that was\n severe for patient at 7 AM on .\n Delirium / confusion\n Assessment:\n Pt agitated, attempting to get OOB. + hallucinations. Uncooperative\n with care. Oriented to person only, at times completely disoriented.\n Picking at tubes and lines.\n Action:\n 0.5 mg haldol IV given as ordered with minimal response. 5-10mg zyprexa\n disintegrating tablet po given as ordered.\n Response:\n Pt calm, cooperative with care.\n Plan:\n 1:1 bedside care, assess neuro status prn, reorient prn, administer\n sedation meds as ordered.\n Respiratory failure, chronic\n Assessment:\n Pt with ins/exp wheezing all lobes posteriorly, crackles heard at\n bases, RR 30s, O2 sat 89-90%. TPA placed in pigtail catheter by ICU\n resident. D5\n NS with 20K infusing at 50 cc/hr.\n Action:\n Neb treatments given as ordered. IVF KVO\nd, 20 mg lasix given as\n ordered. CXR done. Chest tube unclamped, serosanguinous fluid draining,\n + air leak noted.\n Response:\n Pt with sporadic wheezing noted, RR 20s-30s, O2 sats > 94%.\n Plan:\n Continue to assess respiratory status, administer nebs as ordered,\n monitor fluid status.\n" }, { "category": "Nursing", "chartdate": "2190-07-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382645, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases. Audible expiratory wheezing this am\n after repositioning. O2 sat 95-97% on 2.5l nc. Chest tube beginning to\n drain more sanginous following repositioning this am, about 150 in two\n hours. + fluctuation, no crepitus or leak noted.\n Action:\n Nebs given PRN by RT. Chest tube drainage shown to thoracic resident as\n well as Dr. . Will get chest xray this am\n Response:\n Pt breathing comfortably.\n Plan:\n Continue to monitor output, follow up on chest x-ray, continue nebs as\n needed\n Delirium / confusion\n Assessment:\n Pt remains confused, appears to be hallucinating. Not answering\n questions appropriately and not always looking at RN when spoken to.\n Agitated at times, refusing meds. Moving all ext. combative at times.\n L pupil appearing to be fixed and dilated this am, R pupil brisk. ?\n change, not noted until this point.\n Action:\n Seroquel given for sleep. Dr. and thoracic resident shown\n pupils and performed neuro exam. NMED resident consulted and pupil\n believed to be surgical.\n Response:\n Pt remains confused and delirious, Seroquel uneffective\n Plan:\n ? need for CT, possibly increased Seroquel\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382537, "text": "Respiratory failure, chronic\n Assessment:\n SOB on exertion\n LS clear upper, crackles noted at baseline\n Chext x-ray x 2 this shift\n Chest tube to water seal with serous drainage\n Action:\n 2 l/m O2 via NC\n OOB to chair\n Repositioned frequently\n Chest CT done\n IP presently performing Ultrasound of axillary fluid\n collection, may attempt to drain if possible\n Response:\n O2 sats 99% on\n Respiratory status appears comfortable\n No further SOB\n Plan:\n Continue to monitor\n Continue to encourage deep breathing\n Atrial fibrillation (Afib)\n Assessment:\n This morning patient in AFIB, 90\ns-100\n On Amiodarone drip\n On Levophed drip\n Action:\n Self converted to NSR @ 0840\n Levophed weaned\n Response:\n Remains in NSR\n Still requiring small dose of vasopressor, turned off @ 1700\n Plan:\n Continue to monitor\n Treat electrolytes as needed\n Patient and family support\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC this AM 35.8 from 48.3\n Cultures pending\n Action:\n Vanco and Zosyn as ordered\n Urine sample sent to lab\n Chest CT done\n Levophed to support blood pressure\n TLCL placed\n TTE done\n Response:\n Improved tenuous septic picture\n Plan:\n Follow up on culture results\n Continue to monitor vitals, temp, s+s of infection\n Antibiotics as ordered\n Patient and family support\n Pain control (acute pain, chronic pain)\n Assessment:\n Continues to have back pain\n Action:\n Tylenol ordered around the clock\n Lidocaine patch to back\n OOB to chair\n Frequent repositioning\n Response:\n Pain level improved\n Plan:\n Continue to monitor\n Delirium / confusion\n Assessment:\n Alert and oriented to herself and the month\n Recognizes family members and is able to have a conversation\n No short term memory\n Doest not remember she is in the hospital\n Action:\n Geriatric consult\n Family at bedside most of shift\n Nursing in room and reorienting often\n Electrolytes treated\n Response:\n Remains confused\n Plan:\n Continue to ensure safety by having bed in low locked\n position\n Bed alarm on\n Frequent reorientation\n Family at bedside when at all possible\n Patient and family support.\n" }, { "category": "Nursing", "chartdate": "2190-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382821, "text": "Respiratory failure, chronic\n Assessment:\n Lungs clear with diminished bases.\n Slightly dyspneic when getting OOB, difficulty recovering\n O2 sat 97-100% on 4 L nc\n Chest tube dry suction draining large amts serosang drainage\n Action:\n Albuterol nebs prn\n OOB to chair most of shift\n Response:\n Pt comfortable, no further episodes SOB\n Plan:\n Continue to monitor CT output\n nebs prn\n OOB to chair as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with acute and chronic back pain, worse with turning\n Action:\n Tylenol given\n Lidocaine patch applied\n OOB to chair\n Response:\n Denies pain\n Plan:\n Cont med regimen, activity\n" }, { "category": "Nursing", "chartdate": "2190-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382532, "text": "Respiratory failure, chronic\n Assessment:\n SOB on exertion\n LS clear upper, crackles noted at baseline\n Chext x-ray x 2 this shift\n Chest tube to water seal with serous drainage\n Action:\n 2 l/m O2 via NC\n OOB to chair\n Repositioned frequently\n Chest CT done\n IP presently performing Ultrasound of axillary fluid\n collection, may attempt to drain if possible\n Response:\n O2 sats 99% on\n Respiratory status appears comfortable\n No further SOB\n Plan:\n Continue to monitor\n Continue to encourage deep breathing\n Atrial fibrillation (Afib)\n Assessment:\n This morning patient in AFIB, 90\ns-100\n On Amiodarone drip\n On Levophed drip\n Action:\n Self converted to NSR @ 0840\n Levophed weaned to lowest dose, unable to stop due to\n hypotension when attempted\n Response:\n Remains in NSR\n Still requiring small dose of vasopressor\n Plan:\n Continue to monitor\n Treat electrolytes as needed\n Patient and family support\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC this AM 35.8 from 48.3\n Cultures pending\n Action:\n Vanco and Zosyn as ordered\n Urine sample sent to lab\n Chest CT done\n Levophed to support blood pressure\n TLCL placed\n TTE done\n Response:\n Improved tenuous septic picture\n Plan:\n Follow up on culture results\n Continue to monitor vitals, temp, s+s of infection\n Antibiotics as ordered\n Patient and family support\n Pain control (acute pain, chronic pain)\n Assessment:\n Continues to have back pain\n Action:\n Tylenol ordered around the clock\n Lidocaine patch to back\n OOB to chair\n Frequent repositioning\n Response:\n Pain level improved\n Plan:\n Continue to monitor\n Delirium / confusion\n Assessment:\n Alert and oriented to herself and the month\n Recognizes family members and is able to have a conversation\n No short term memory\n Doest not remember she is in the hospital\n Action:\n Geriatric consult\n Family at bedside most of shift\n Nursing in room and reorienting often\n Electrolytes treated\n Response:\n Remains confused\n Plan:\n Continue to ensure safety by having bed in low locked\n position\n Bed alarm on\n Frequent reorientation\n Family at bedside when at all possible\n Patient and family support.\n" }, { "category": "Nursing", "chartdate": "2190-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382857, "text": "Delirium / confusion\n Assessment:\n Pt sleeping intermittently throughout the night, arousable to voice.\n Oriented to\n and person only. Can answer simple questions\n appropriately. Pupils equal, left appearing sluggish but reactive. No\n delirium noted this shift, pt is pleasant and only mildly confused at\n times. Moving all ext on the bed, following all commands.\n Action:\n Neuro assessment Q 4 hours. Reoriented at needed. Pt in calm quiet\n atmosphere\n Response:\n Pt resting comfortably throughout the shift\n Plan:\n Continue to monitor neuro status, reorient and offer emotional support\n as needed\n Problem - Description In Comments\n Assessment:\n Low UOP, 10-20cc for a few consecutive hours overnight. Pt\ns fluid\n balance even at midnight. CVP 1-2\n Action:\n Dr. notified, Lasix 10mg given IV x 1\n Response:\n Urine output improving this am, averaging 80-100cc/hr\n Plan:\n Continue to monitor uop and assess need for additional Lasix\n Bradycardia\n Assessment:\n HR decreasing to 30\ns at times, pt sleeping. BP stable.\n Action:\n Resident paged, EKG done, labs sent, Atropine at the bedside.\n Response:\n Pt asymptomatic.\n Plan:\n Continue to monitor HR, labs, atropine at the bedside\n" }, { "category": "Physician ", "chartdate": "2190-07-05 00:00:00.000", "description": "Intensivist Note", "row_id": 382945, "text": "SICU\n HPI:\n F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Atorvastatin 6.\n Calcium Gluconate 7. Docusate Sodium\n 8. Furosemide 9. Heparin 10. Insulin 11. Lansoprazole Oral\n Disintegrating Tab 12. Lidocaine 5% Patch\n 13. Magnesium Sulfate 14. Magnesium Sulfate 15. Metoprolol Tartrate 16.\n Morphine Sulfate 17. Piperacillin-Tazobactam\n 18. Potassium Chloride 19. Quetiapine Fumarate 20. Senna 21. Sodium\n Chloride 0.9% Flush 22. Sodium Phosphate\n 23. Tiotropium Bromide 24. Vancomycin 25. Venlafaxine\n 24 Hour Events:\n Pleural fluid growing strep, amiodarone d/cd, stable, eating ground\n diet, no new issues\n Post operative day:\n POD 6 s/p thoracic pigtail drain placement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:10 PM\n Other medications:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 61 (60 - 71) bpm\n BP: 107/40(56) {90/30(47) - 124/76(80)} mmHg\n RR: 19 (17 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.1 kg (admission): 57 kg\n Height: 65 Inch\n CVP: 2 (0 - 12) mmHg\n Total In:\n 1,470 mL\n 255 mL\n PO:\n 180 mL\n Tube feeding:\n 200 mL\n 100 mL\n IV Fluid:\n 1,090 mL\n 155 mL\n Blood products:\n Total out:\n 1,038 mL\n 120 mL\n Urine:\n 778 mL\n 120 mL\n NG:\n Stool:\n Drains:\n 150 mL\n Balance:\n 432 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present)\n Skin: Rash:\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 712 K/uL\n 8.3 g/dL\n 94 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 109 mEq/L\n 141 mEq/L\n 26.7 %\n 19.4 K/uL\n [image002.jpg]\n 06:13 AM\n 07:39 AM\n 07:53 AM\n 03:00 PM\n 09:22 PM\n 03:12 AM\n 02:06 AM\n 03:21 AM\n 02:05 AM\n 02:04 AM\n WBC\n 27.0\n 29.4\n 21.2\n 26.2\n 19.4\n Hct\n 31.6\n 30.3\n 29.7\n 30.7\n 26.7\n Plt\n 02\n 712\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.6\n 0.5\n 0.5\n 0.5\n TCO2\n 17\n 21\n Glucose\n 94\n 140\n 102\n 101\n 116\n 107\n 109\n 94\n Other labs: PT / PTT / INR:14.0/50.2/1.2, CK / CK-MB / Troponin\n T:23//<0.01, Differential-Neuts:81.0 %, Band:1.0 %, Lymph:8.0 %,\n Mono:5.0 %, Eos:3.0 %, Lactic Acid:0.7 mmol/L, Albumin:2.0 g/dL,\n LDH:208 IU/L, Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n BRADYCARDIA, PROBLEM - ENTER DESCRIPTION IN COMMENTS, RESPIRATORY\n FAILURE, CHRONIC, DELIRIUM / CONFUSION, PAIN CONTROL (ACUTE PAIN,\n CHRONIC PAIN), SEPSIS WITHOUT ORGAN DYSFUNCTION\n Assessment and Plan: 90 F w/ loculated pleural effusion s/p pigtail\n placement complicated by Afib, now in sinus rhythm\n Neuro: alert, seroquel for agitation /insomnia prn, morphine for pain.\n CVS: Afib controlled on metoprolol, now in sinus\n Pulm: empyema from PNA, s/p pigtail placement by IP, on Vanc/Zosyn,\n pleural fluid cx sent, no further intervention on apical effusion per\n thoracics, TPA given via pigtail , , cx with sparse growth of\n Streptococcus\n GI: bowel regimen, home PPI\n FEN: Regular diet, KVO. On home lasix. Repleting electrolytes\n Renal: Stable UOP, on home lasix.\n Heme: on SCH for proph\n Endo: RISS\n ID: Vanc/Zosyn for loculated pleural effusions, pleural fluid growing\n Streptococcus\n TLD: foley, RSC CVL, CT pigtail\n Wounds: none\n Imaging: CXR\n Consults: Neurology, ID dept, Thoracic Surgery, Geriatrics\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines: foley, RSC CVL, CT pigtail\n Multi Lumen - 08:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2190-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 382634, "text": "89 y.o. F with CAD s/p MI, atrial fibrillation (not on\n anticoagulation), frequent falls, and CHF (EF >65% ) who\n presented to the ED on with RUQ and R chest pain that was\n severe for patient at 7 AM on .\n Delirium / confusion\n Assessment:\n Pt agitated, attempting to get OOB. + hallucinations. Uncooperative\n with care. Oriented to person only, at times completely disoriented.\n Picking at tubes and lines.\n Action:\n 0.5 mg haldol IV given as ordered with minimal response. 5-10mg zyprexa\n disintegrating tablet po given as ordered.\n Response:\n Pt calm, cooperative with care.\n Plan:\n 1:1 bedside care, assess neuro status prn, reorient prn, administer\n sedation meds as ordered.\n Respiratory failure, chronic\n Assessment:\n Pt with ins/exp wheezing all lobes posteriorly, crackles heard at\n bases, RR 30s, O2 sat 89-90%. TPA placed in pigtail catheter\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-07-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 383010, "text": "F R flank pain x 1 day, pleuritic, no inciting event, loculated\n pleural effusion on CT s/p pigtail placement\n Chief complaint:\n As above\n PMHx:\n Frequent Falls\n CAD - s/p MI years ago\n CHF - ? last ECHO EF 70%\n Atrial fibrillation\n Chronic venous stasis with b/l lower extremity edema\n Constipation\n Degenerative disc disease followed by ortho\n Respiratory failure, chronic\n Assessment:\n Patient continues to have pigtail chest tube in place to dry suction\n draining 50 cc serosanguinous fluid. Lungs sound diminished on right\n side, clear on left side. On 5 L NC. O2 sats 96-100%.\n Action:\n Continues on antibiotics however vanco discontinued,\n Patient encouraged to cough and deep breathe frequently, chest PT,\n OOB to chair,\n O2 weaned to 3 L NC.\n Response:\n O2 sats continue to be 96-100%, Patient denies SOB.\n Plan:\n Continue to monitor, transfer to 9 awaiting available bed, rehab?\n Delirium / confusion\n Assessment:\n Patient oriented x , although confused at times. Able to take po\n however coughing frequently.\n Action:\n - reoriented frequently,\n - speech and swallow called for a reevaluation.\n Response:\n Patient calm and easily reoriented,\n Patient did well with speech and swallow eval, able to have soft solids\n and thin liquids.\n Plan:\n Continue to monitor, reorient as needed.\n" }, { "category": "ECG", "chartdate": "2190-07-04 00:00:00.000", "description": "Report", "row_id": 268252, "text": "Artifact is present. Sinus rhythm. Right bundle-branch block. Non-specific\nST-T wave changes. Compared to the previous tracing ST-T wave changes are\nnew.\n\n" }, { "category": "ECG", "chartdate": "2190-07-01 00:00:00.000", "description": "Report", "row_id": 268482, "text": "Sinus tachycardia. Baseline artifact. Left atrial abnormality. Right\nbundle-branch block. Compared to the previous tracing of the rate has\nincreased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2190-06-30 00:00:00.000", "description": "Report", "row_id": 268483, "text": "Sinus rhythm. Right bundle-branch block with left anterior fascicular block.\nNon-specific ST-T wave changes. Compared to tracing #2 atrial fibrillation is\nnow absent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2190-06-30 00:00:00.000", "description": "Report", "row_id": 268484, "text": "Atrial fibrillation with a rapid ventricular response. Limb lead reversal.\nRight bundle-branch block. Non-specific ST-T wave changes. Compared to\ntracing #1 atrial fibrillation and lead reversal are new.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2190-06-29 00:00:00.000", "description": "Report", "row_id": 268485, "text": "Sinus rhythm. Short P-R interval without other signs of pre-excitation.\nRight bundle-branch block with left anterior fascicular block. Left\nventricular hypertrophy. Non-specific ST-T wave changes. Compared to the\nprevious tracing earlier same date no significant changes.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2190-06-29 00:00:00.000", "description": "Report", "row_id": 268486, "text": "Baseline artifact. Sinus rhythm. Left anterior fascicular block. Right\nbundle-branch block. Since the previous tracing of the rate is faster.\n\n" } ]

[ { "category": "Echo", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 92987, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 66\nWeight (lb): 200\nBSA (m2): 2.00 m2\nBP (mm Hg): 138/61\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 14:23\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Compared with\nthe findings of the prior study, there has been no significant change.\n\nConclusions:\n1. The left atrium is moderately dilated. The right atrium is dilated.\n2. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is difficult to assess but is probably normal (LVEF>55%).\n3. The right ventricular cavity is markedly dilated. There is severe global\nright ventricular free wall hypokinesis.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n6. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension.\n7. Compared with the findings of the prior report (tape unavailable for\nreview) of , there has been no significant change.\n\n\n" }, { "category": "Echo", "chartdate": "2155-11-27 00:00:00.000", "description": "Report", "row_id": 92988, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion.\nStatus: Inpatient\nDate/Time: at 15:30\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand/or RV.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality as the patient was difficult to position.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and systolic function are\ngrossly normal (LVEF>55%). Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2155-11-29 00:00:00.000", "description": "Report", "row_id": 246217, "text": "Sinus rhythm. No significant change compared to tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2155-11-29 00:00:00.000", "description": "Report", "row_id": 246218, "text": "Sinus rhythm. No significant change compared to the previous tracing\nof .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2155-11-27 00:00:00.000", "description": "Report", "row_id": 246219, "text": "Sinus bradycardia\nPossible left ventricular hypertrophy\nNonspecific diffuse T wave flattening - cannot exclude ischemia\nSince previous tracing, T wave changes noted and ventricular premature complex\nabsent\n\n" }, { "category": "ECG", "chartdate": "2155-11-27 00:00:00.000", "description": "Report", "row_id": 246220, "text": "Sinus bradycardia.\nLeft axis deviation\nLeft ventricular hypertrophy\nInferior ST segment elevation with lateral T wave inversion - ? ischemia\nSince previous tracing, further ST-T wave changes seen\n\n" }, { "category": "ECG", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 246221, "text": "Ventricular paced rhythm\nSince previous tracing, paced rhythm noted\n\n" }, { "category": "ECG", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 246222, "text": "Sinus bradycardia\nPossible left ventricular hypertrophy\nInferior ST elevation - with lateral T wave inversion - ? injury/ischemia\nSince previous tracing, pacing absent and ST-T wave changes noted\n\n" }, { "category": "ECG", "chartdate": "2155-11-30 00:00:00.000", "description": "Report", "row_id": 245993, "text": "Sinus rhythm.\nLeft axis deviation\nPossible left ventricular hypertrophy (aVL=12 millimeter)\nInferior ST elevation - cannot rule out myocardial injury\nLateral T wave changes are probably due to ventricular hypertrophy\nSince previous tracing of , more suggestive of left ventricular\nhypertrophy\n\n" }, { "category": "Nursing/other", "chartdate": "2155-11-27 00:00:00.000", "description": "Report", "row_id": 1298599, "text": "CCU NSG NOTE: ALT IN CV/MS\nO: For history see admission note.\nCV: Pt admitted from lab post 2 stents to RCA c/b bradycardia, pauses and hypotension. She was transiently on dopamine and had pacing wire placed as well as IABP. Echo showed poor RV activity, LV looked OK.\nPt arrived pain free only on D5W with 3 amp bicarb at 100/hr. She was v-paced at 74 with her own hr occasionally going over the 74. Per Dr pacer rate was decreased to 54 at 1700 with her sinus rate in mid 60s. By 1830 her maps had dropped and rate was increased to 75 with occasional PVCs. Sensitivity increased from 8 to 4. Maps did not increase and pt is now receiving 500NS bolus. She remains on IABP 1:1 with excellent augmentation and unloading. Assisted systole has ranged 70s/ assisted systole 80-100s and BAEDPs 50s and maps in 70-80s until ~1830. Now with bolus maps increasing to 70s. She continues on bicarb drip with second liter. Heparin was restarted at 1600 at 800u/hr. She initially had oozing in L groin pacemaker site but that has ceased. She has some eccymosis in R groin-IABP site. All pulses dopplerable. CKs pending.\nHEME: Crit down to 27.6 from 31. 1U PRBC hung at 1730. With drop in maps rate of blood running was increased. Pt tolerating it.\nRESP: Some crackles heard at bases. Pt sating 97-99% on 2L NP.\nGI: Taking sips of water, but not clear enough to safely eat.\nRENAL: Foley draining clear urine. Urine output has decreased since admission. SHe is ~800cc pos for the day.\nMS: Pt arrived oriented X 3, but as the afternoon went on she became more delerious, picking at air, hallucinating and trying to get OOB. Her daughters assisted in keeping her calm, and at no time was she severly aggitated. She received haldol 2mg IV at 1600, 1800 and 1900. She is sleeping off and on. SHe is not now restrained. SHe will have sitter at 11pm. Pt has history of severe delerium on last admission.\nA: ?RV infarct/requiring pacemaker/transfusion/dropping maps\nP: Check results of CKs. SEnd crit when transfusion done. More boluses from dropping maps. Consider dobutamine/dopamine for hemodynamic compromise.Monitor groins and pulses. CHeck PTT at 10pm.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 1298600, "text": "CCU NPN 1900-0700\nS: \" Get the hell away from me! \"\nO: pt. becoming increasingly agitated , confused and delerious as night went on. yelling, trying to sit up, picking. haldol total 6mg between 20-2300 with poor effect. 4mg at 2330 when pt. was escalating, screaming. family at bedside but becoming increasingly frustrated themselves without alot of effect in calming pt. family went home at 0100- pt. restrained with bilat. soft wrist and left leg restraints. either RN or aide with pt. at all times. after discussion with team- given .5mg ativan with little effect.\nthen given haldol 5mg at 0145 and again at 0330. pt. finally seems to be resting more comfortably, less restess with longer periods of semi-sleep.\nshe is Ox1. taking sips of water with sponge. speaking in english and also italian...\n\nCV: HR 74-78 Vpaced with occas. PVC's. pacer checked: vent. stim. threshold at 3. MA currently at 6. HO aware. baseline rate 60-75\nK+ 3.7- 20meq KCL CPK 183/16.\nIABP 1:1, MAP 60-97 . some wave dampening req. mannual aspiration and flushing x3. fair to good augmentation. good syst. unloading.\n- heparin gtt 800u/hr. PTT 56. (goal 50-70)\n\nResp: LS diminished at bases. confusion making examination difficult\nO2 2lnc. sats 96%. RR 16-20\n\nGU: foley 35-60cc/hr. + 1.5L for and + 800cc since 12am\nGI: NPO. swabing mouth prn. no BM. hypo BS. ABD soft.\nendo: insulin gtt 4u/hr -> current 1.5u/hr. FS low 80 to 120-140's since 12am. Bicarb gtt at 100/hr x2L completed at 0500.\n\nheme: first UPRBC complete at . HCT unchanged at 27.6. #2UPRBC up at 2200-0200. AM HCT pnd at 0400.\n\npulses: DB +/ PT 1+. right fem. IABP site D/I. left fem. TV pacing wire site D/I. no hematomas.\n\n\nA: acute delerium/confusion- gradual improvement with haldol\n stable hemodynamics with transvenous pacing/IABP\n HCT drop req. 2UPC's\nP: contin. to follow/monitor MS/neuro for change/improvement. haldol prn. ? able to D/C IABP today. assess pacing and possible weaning.\n- follow hcts, insulin gtt, q1hr FS. family support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 1298601, "text": "addendum\n0400- pt. beginning to have periods of snoring/sleeping alternating with occas. picking at gown and mumbling. much more quiet.\nhands/left leg remain restrained.\nK+ 3.1/Mg+ 1.4- repletion begun.\nCK elevated to 600.\nHCT stable at 30.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 1298604, "text": "CCU NPN 1600-\nIABP pulled at 1505. While clamp in place pt became hypotensive requiring ivf and ^ pmr rate, w/ improvement in bp. ~ 1700 pt c/o r lower abd, and back pain. Seen by cardiology fellow, lg hematoma. Initially hemodynamically stable, seen by vascular surgery who felt if hemodynamically stable surgery not necessary. then bp down to 69, dopa started and ivf given for total 1250cc.Also given 1 mg Atropine, total 75 mg fentanyl for pain control, and 2 mg haldol for agitation. ,SATS down to 88, 100% NRB added, and SATS 100%. ultrasound done showing lg pseudoaneurysm and lg actively bleeding hematoma. Pt received 2 u prbc, hct at 1800 31. Reseen by surgery and pt taken to OR for repair. During this episode pmr rate changed several times by cardiology, and pt becoming more pacer dependent. Surgeons and cardiologist spoke w/ family, they are aware of the plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-29 00:00:00.000", "description": "Report", "row_id": 1298605, "text": "Respiratory Care\nPt was received from o.r. intubated with 7.5 oral et tube taped at 21 cm @ lips. Bilateral breath sounds are equal, clear. Maintained on a/c overnight with excellent oxygenation, abgs within normal limits. Pt is sedated and not breathing above the vent. Plan is to wean and extubated later today.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-29 00:00:00.000", "description": "Report", "row_id": 1298606, "text": "CCU NPN 1900-0700\nO: 77yo female admitted for elective cath. s/p stents x2 c/b brady/hypotension req. atropine, dopa, transvenous pacing wire and IABP. post cath course c/b acute confusion, delerium rx with haldol with fair responce. stable with decrease confusion and hemodynamically stable. IABP weaned and d/c'd c/b hypotension and rapidly expanding hematoma. taken to OR for repair at 1900.\nfindings in OR: massive RP hematoma, 3mm hole in R iliac artery.\nArrived back to CCU ~ . intubated on propofol gtt.\ns/p right groin exploration/evacuation of hematoma and repair of artery. received total 5U PC'c, 2U FFP and 1U plts. EBL 2L.\nCV: HR 54-60's SB with occas. PVC, PAC's. K+ 4.6 on admit. pacer set at 50BPM at MA .6. tested at 0300 which found failure to sence and pace approp. for periods of time. resident aware.\nBP via left radial aline (OR) 113-130's/50-60. initially high 160-180/, trending down on own.\n- no heparin gtt.\n- last CK contin. to trend up to 1000 .\n\nheme: HCTs ordered q2hr. 2200 31.9. trending down to 29.2 at 0400. resident aware- will transfuse for <28. 6uPC's ready in BB.\nright fem. surgical site with DSD. small amt of SS drainage noted but did not need changing/reinforcing. JP draining ~ 100cc q4hr bloody drainage. pulses +. extrem. warm.\n\nResp: currently on AC 650x9/.50/5peep. sats 99%. ABG 7.41/38/102. suctioned for scant thin secretions. LS diminished.\nNeuro: arrived on propofol 20mcq/k/min. currently on 25mcq for adaquate sedation and comfort. pupils 2mm and brisk. + cough/gag. inc. responsiveness with suction/turning etc. no spont. movement. hands restrained for safety.\n\nGU: foley draining 30-80cc/hr. (+)4.8L and (+) 6.5 LOS\nGI: NPO. ABD soft , distented. hypo BS. no stool.\nendo: restarted on insulin gtt at 2u/hr. currently at 6.5u/hr for FS 180-120.\naccess: left radial aline, left fem. pacing introducer with side arm.\nPIV x2.\n\nsocial: family here and updated by MD and RN. went home for night. 5 children/husband.\n\nA: s/p fem. artery repair\nP: HCT q2hr. transfuse for HCT <28. follow hemodynamics, u/o. drain JP q4hr and prn. monitor HR/rythm for change. test pacing wire with team. follow lytes, FS q1hr, insulin gtt. family support.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-29 00:00:00.000", "description": "Report", "row_id": 1298607, "text": "CCU Nursing Progress Note 7am-7pm\nS: Thank you all!\n\nO: Neuro - Pt initially on Propofol while intubated, but dc'd at 9am. Pt extubated 315pm (see below), and pt alert and oriented x3. Pt does say that she gets nervous, and asks for something to take her nerves away at around 7pm.\n\nID - T max. 99.3 po\n\nCV - BP 106/50 initially in shift with HR 50-60 NSR with rare unsensed paced beats. At 9am, BP down to 80/ with HR stable at 68. Rx with 1liter IVF over 1 hr with subsequent BP up to 131-114/60 with no further hypotension during day. Temp pmr wire intact via l groin, but is not consistently sensing. PMR turned off at 10am and was removed at 1130am. HR post pmr removal is stable at 73-80 NSR with rare PVC's.\n\nResp - Initially orally intubated on 50%/ 650/ 5 peep/ 5 ps with diminished bs at bases. Changed to ps only at 930 as propofol was dc'd at 9am. Tolerated ps wean and was successfully extubated at 330pm. Pt is expectorating thick blood tinged sputum. LS now have some faint crackles at l base. O2 face tent on 40%.\n\nGU - U/o is low at 30-100/hr. U/o increased post ivf bolus. House staff aware.\n\nGI - Abd is obese with hypoactive BS. OGT passed this am for oral medications, but was dc/d with extubation. Tolerating ice chips.\n\nHeme - DSD on R groin with jp bulb drain. Dsg has some bloody ooze under tape, and is marked at 7am. Slight increase since. JP drain draining approx 150cc this shift. Ecchymotic groins noted. L groin temp pmr dc'd at 1130am, and cordis dc'd at 3pm. DSD dry and intact. Pulses +2/D bilat. HCT q2-3hrs is increasing 29.9 to 31.2\n\nEndo - Regular insulin IV continues with fingersticks q1hr until control obtained, then q2hrs. See careview for all fs and insulin titrating.\n\nSocial - Husband and 2 daughters here most of the day and are aware of situation and plan.\n\nA: Stable s/p RCA stents c/p hypotension then r/p bleed\n\nP: Cont monitoring HCT's per order through night. Cont monitoring of fingersticks and titration of insulin as necessary/ per protocol. Monitor HR and BP, resp status and attempt to decrease o2 requirement. Encourage c and db s/p extubation. Close monitoring of mental status as pt has hx of agitation while hospitalized. Haldol prn.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-30 00:00:00.000", "description": "Report", "row_id": 1298608, "text": "CCU Nursing Progress Note 7p-7a\nS: \"I feel okay\"\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx3. Cooperative. Pt denies any pain. MAE. PEARL. No issues w/ delirium . No Haldol given. Pt requesting sleep aid/ \"pill to relax\". Pt was given Trazadone po w/ marginal effect. Pt dozing in naps .\n\nCV: VSS. HR 66-87. No ectopy noted. BP via left radial arterial line 102-128/46-57. MAPs>65. Pt denies CP. Pt tolerating dc of temp pacing wire w/o difficulty. Hct 28.7. HO aware. Since BP is stable will hold off on transfusion and cont to follow serial HCT q6hrs. L femoral groin site remains stable. Right groin dsg changed by vascular. Prior to dsg change no advancement of ooze noted. JP to gravity. a total of 140cc s/s drainage collected.\n\nResp: LS cta in upper lung fields. Bibasilar crackles auscultated in bases but improved in comparison to initial assessment. RR 19-31. Pt denies SOB/ difficulty breathing. O2 sats 94-98%. ABG 7.48/38/71. Pt remains on 5L supplemental O2 via NC.\n\nGI/GU: Abd obese. Hypoactive BS. Declining soup brought in by family. Minimal intake. BMx4 . 100cc Liquid->hard->formed->lg soft. Trace guiac positive. F/C to gravity. UO poor initially but pt was given 20 mg IV Lasix at 00. Pt diuresed for approx 1L. Pt -1284 for 24hrs/ remains 5.3L positive LOS. BUN/Cr 17/1.1.\n\nID: Afebrile. Tmax 98.6 po. WBC 11.5. No abx .\n\nEndo: BS obtained q1-2 hrs. pt labile and ^ w/o intake. Found I/Cream cover near window sill ? given to pt by family. BS trending downward . Insulin gtt 1.5u/hr to 3.0u/hr back to 1.5u/hr this am as indicated.\n\nSocial: Son/ daughter in law into visit.\n\nA/P: 77 yo female s/p elective cath, stent to RCA x2 c/b Bradycardia/hypotn requiring IABP support/ Atropine/ temp pacing wire for pause. Bilateral hematoma, Femoral groin bld. JP drain cont to drain s/s drainage. Pt tolerating d/c of temp wire. No issues . VSS. BS labile after ? icecream intake. Normalizing this am. ? D/C insulin gtt and starting sliding scale. consult necessary to evaluate uncontrolled scale at home. Hct <30. HO aware cont to follow q6. Cont to support pt and family as indicated. Advance diet and activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-30 00:00:00.000", "description": "Report", "row_id": 1298609, "text": "CCU Nursing Progress Note 7am-7pm\nS: I have some pain in my leg\nO: Pt describes pain in l foot which is relieved with ii Tylenol and increasing movement. OOB x2 with 3 nurse assist and tolerated sitting in chair x1hr.\n\nID - Afebrile\n\nCV - HR 48-80 nsr with rare pvc. K+3.3 given 60meq KCl po. BP 96-140/50-60. No cardiac meds started at this point d/t occasional bradycardia to 40's. L pmr dsg d/i and ecchymotic area noted laterally. R iliac art repair site changed by surgery with j/p drain in place and is stripped q3-4hrs. Pulses +3/d bilaterally. l foot is cooler than r.\n\nResp - fine base rales audible. O2 3-5l n/p. Titrated up as pt is a mouth breather while asleep.\n\nGI/Endo - Passed OB+stool x1 and was frequently on bed pan for gas. Appetite is poor as pt is picky eater. Regular insulin gtt changed to glargine at HS and sliding scale. See careview for all blood sugars.\n\nGU - Urine output 25-50cc/hr clear amber urine via foley.\n\nSocial - Multiple family members throughout day and are aware of status and plan. Request social service consult for assistance at home vs. inpatient rehab.\n\nHeme - Pnd Hct at 1830.\n\nA: Stable s/p RCA stents/ iliac bleed and repair\n\nP: Cont monitor vs, HR and BP. Discontinue Aline in am. Monitor resp status and I&O and assess need for lasix this evening. Continue increase activity as tolerated. Cont twice /day checks on HCT.\nConsults - Social service, diabetic, PT. Family would like to see social service as well.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-12-01 00:00:00.000", "description": "Report", "row_id": 1298610, "text": "CCU Nursing Progress Note 7p-7a\nS: \"I'm so thirsty\"\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx3. Pleasant and cooperative. MAE. PEARL. Pt slept most of shift with minimal interruption. Pt denies any pain.\n\nCV: . Remains off of support of PPM/IANP. HR 68-78. Rare PVC noted. ABP 103-134/37-53 via right radial arterial line. MAPs>60. Plan today by HO was to initiate Atenolol which has since been placed on hold after pt experienced some bradycardia on prior shift. No issues w/ HR/BP. Pt remains on post cath regimen of ASA, Plavix and Lipitor. Right iliac arterial dsg site CDI. JP remains to gravity. Left PPM dsg site CDI. Both groins have old ecchymosis upon assessment. +2 DP/ +1 PT. AM labs still pending.\n\nResp: LS cta in upper lung fields. Bibasilar crackles auscultated anteriorly. RR 20-25. O2 sats 94-97% on 5L supplemental O2 via NC. ABG 7.43/39-95. Pt denies SOB/difficulty breathing.\n\nGI/GU: . Abd obese. Pt picky eater declining soup brought in by family as well as hospital food. Minimal intake . Pt tolerating clr liquids and icechips w/o difficulty. +BS. No stool. F/C to gravity. UO 100-140cc every 2 hrs. Pt was -1200 at 2300 and -500 since MD and remains +4.8L LOS. Was not ordered for additional diuresis.\n\nID: Tmax 100.3. Pt c/o being very hot. Requested removal of blankets. Room was very hot and when thermostat was checked it was noted to be almost 80 degrees. No Tylenol was given. Recheck found temp to be 98.6 po. Pt remains off all abx at this time.\n\nSkin: Intact. Bilateral groin sites remain stable. +1 peripheral edema noted. No breakdown on backside.\n\nSocial: Daughter called and updated by RN. Husband then updated by RN as well. No additional calls or visitors .\n\nEndoL: Insulin gtt changed to sliding scale on prior shift. Pt was given 10 units Glargine as well as 2 units Humalog per sliding scale. Cont FS QID.\n\nA/P: Elective cath following + ETT during preop evaluation for back surgery. RCA intervention c/b bradycardia and Hypotn requiring IABP/ Atropine and temp pacer for pause. Pseudoaneurysm following d/c of IABP requiring multiple bld products and surgical repair. HCT cont to trend downward. Keep JP drain in for now. Vascular surgery cont to follow iliac artery repair. Cont to follow HCT and transfuse if indicated. No further episodes of bradycardia . Start BB/ACE-I doses as indicated and titrate as BP tolerates. Cont to advance diet and activity as tolerated. ? call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 1298602, "text": "CCU NSG NOTE: IABP\nO: PT continues on IABP now 1:1 with plans to pull later this afternoon. Pt has excellent augmentation and has been unloading 15-31p. Augmented diastole has ranged 66-98, augmented diastole 99-125, balloon aortic end diastolic pressure 42-45 with maps 60-90. Maps were low when hr was in the low 40s. Maps improved with 2 X 250 NS boluses. Pt tolerated wean to 1:3. She was back on 1:1 at 1300 at which point heparin was shut off. ACT will be done shortly in preparation for pull later today. Groin is dry with no ooze or hematoma. All pulses are dopplerable, CSM nl. Feet are warm.\nA: Stable during wean/heparin off/IABP to come out\nP: Check ACT. Notify Dr with ACT results.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-28 00:00:00.000", "description": "Report", "row_id": 1298603, "text": "CCU NPN 7a-3p\nS: \"I'm doing better\", no c/o pain\nO: see carevue for trends in VS/event data\nMS: A&Ox2-3, follows commands, answers appropriately, MAE, continues picking at air/blankets, easily reoriented. SWR on, sitter and family in room. 2mg haldol IV @ 0900, Psych clinical specialist up to eval, suggests 5mg Haldol @ dusk and PRN per sx requirement t/o night.\n\nCV: see above for IABP data. ACT 136, DR. notified. Temp v-pacing wire precariously placed, at times not sensing appropriately, sensitivity threshold now 1.5mA, stim threshold 0.8mV, up to 1.5mV to ensure capture. Paced rate decreased to 30 for eval of intrinsic rhythm (35-65), pt. initially SB w/ MAP 60-65, Rate increased 50's-60's w/ occas PVC's after 250cc NS bolus x2. Bedside ECHO today showed good LV/RV fxn, 2+MR, +TR. Pertinent labs: Hct 30(27) after 2UPRBC onoc, K 3.1, repleated w/ 80meq KCl, Mg 1.4 repleated w/ 4gm MgSO4, CK/MB/Trop 660/53/1.05 not peaked, all 1400 labs pending.\n\nRESP: RR 16-20, SpO2 95-98% on 4L NC. Bibasilar crackles 1/2 up. dependent R>L.\n\nGI: tol PO's liq/soft, needs reverse t-. ABD S/NT/ND +BS/-BM\n\nGU: urine yellow/pink/ tinged 30-100cc/hr, increased w/ boluses. +1400cc since MN, +3L for LOS. BUN/CR stable, 1400 Cr pending.\n\nENDO: insulin gtt @ 1.5U/hr, BG 99-173\n\nA/P: Awaiting D/C IABP. Plan to leave pacing wire in for further eval of pt. intrinsic rate and ability to remain hemodynamically stable. FS q1hr, titrate insulin gtt protocol. Haldol @ dusk for delerium prophylaxis and PRN t/o night. Cont to monitor u/o, lytes, CV sts, mental sts.\n" } ]

[ { "category": "Radiology", "chartdate": "2147-04-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 953822, "text": " 1:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval. tubes & lines\n Admitting Diagnosis: ATRIAL FIBRILLATION/PERI CARDIAL STRIPPING;PLUS MINSUS MAZE/SDA\\MEDIAN STERNOTOMY; PERI CARDIAL STRIPPING PLUS/MINUS MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with\n REASON FOR THIS EXAMINATION:\n eval. tubes & lines\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old female status post median sternotomy for cardiac\n stripping MAZE procedure.\n\n COMPARISON: None.\n\n AP SUPINE PORTABLE CHEST X-RAY: The patient is status post median sternotomy.\n The cardiomediastinal silhouette is enlarged, consistent with recent surgery.\n A focal lucency overlying the right mid mediastinum is likely postoperative\n pneumomediastinum. An endotracheal tube terminates 3.4 cm above the carina. A\n nasogastric tube descends below the diaphragm and is coiled within the stomach\n fundus. There are twp left and single right chest tubes. Mediastinal drain\n is in appropriate position. Right internal jugular Swan-Ganz catheter\n terminates in the right pulmonary artery, crossing the midline by 1.3 cm.\n\n There is no large pneumothorax on the supine radiograph. Mild atelectasis at\n the left lung base as expected status post surgery. No rib fractures are\n identified. The surrounding soft tissues are unremarkable.\n\n IMPRESSION: No large pneumothorax. Focal lucency overlying the right mid\n mediastinum likely represents postoperative pneumomediastinum, and attention\n to this area should be paid on subsequent followup exams. The right internal\n jugular Swan-Ganz catheter terminates in the proximal right pulmonary artery,\n across from the midline. Additional lines and tubes in good position.\n\n" }, { "category": "Radiology", "chartdate": "2147-04-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 954266, "text": " 11:09 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: ATRIAL FIBRILLATION/PERI CARDIAL STRIPPING;PLUS MINSUS MAZE/SDA\\MEDIAN STERNOTOMY; PERI CARDIAL STRIPPING PLUS/MINUS MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with s/p pericardiectomy\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pericardectomy with multiple chest tubes removed.\n\n PA & LATERAL CHEST: Comparison to two days prior reveal that bilateral chest\n tubes have been removed and a right-sided internal jugular catheter persists\n unchanged in tip position.\n\n Cardiomediastinal silhouette is unchanged with some continued mediastinal\n widening, likely postoperative. Again, opacity at the tube tracts is noted\n possibly representing localized contusion vs scarring. Atelectasis is seen at\n the left base. Otherwise, the lungs again appear relatively clear. Mild\n blunting of the right costophrenic angle is again noted likely representing a\n small effusion. There is no evidence of gross volume overload. No\n pneumothorax.\n\n IMPRESSION: Status post removal of bilateral chest tubes with no evidence of\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2147-04-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 954041, "text": " 4:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: \n Admitting Diagnosis: ATRIAL FIBRILLATION/PERI CARDIAL STRIPPING;PLUS MINSUS MAZE/SDA\\MEDIAN STERNOTOMY; PERI CARDIAL STRIPPING PLUS/MINUS MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with\n\n REASON FOR THIS EXAMINATION:\n \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST FOR LINE PLACEMENT, at 16:11 hours.\n\n HISTORY: None provided.\n\n COMPARISON: .\n\n FINDINGS: The patient has been extubated and the NG tube removed.\n Additionally, the vascular sheath and Swan-Ganz catheter has been exchanged\n for a small bore central venous catheter with the distal tip near the\n cavoatrial junction. Bilateral chest tubes and a pair of mediastinal drains\n remain in place. The lungs are relatively clear save for opacity at the chest\n tubes, likely due to localized contusion. There is mild blunting of the right\n costophrenic angle which may be reflective of a small underlying effusion. No\n frank failure is evident. There is continued mediastinal widening, likely\n secondary to postoperative edema.\n\n IMPRESSION: Exchange of right internal jugular central venous access and\n extubation and removal of NG tube as above.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-09 00:00:00.000", "description": "Report", "row_id": 1521049, "text": "NEURO: PT. ALERT, CONFUSED IN AM- ORIENT X2 (ANSWERING FOR THE YEAR WHEN ASKED MULTIPLE TIMES), MORE ORIENT IN AFTERNOON AND AROUND FAMILY, OOB TO CHAIR X2 WITH 2 ASSIST, OBEYS COMMANDS. LETHARGIC MOST OF DAY BUT ABLE TO HAVE APPROPRIATE CONVERSATION WHEN AWOKEN.\n\nCV: PT. AFIB, BURST OF RAF- AMIODARONE BOLUS 150MG GIVEN, MORE RESPONSIVE TO 500CCNS BOLUS- CURRENTLY HR 90'S, SBP 120-130'S. COUMADIN GIVEN AT 1800.\n\nRESP: PT. LUNGS CLEAR IN UPPER FIELDS, DIMINISHED IN LOWER LOBES, CHEST TUBES TO LCWS WITH NO AIR LEAK NOTED, DRAINING MINIMAL SEROUS DRAINAGE. +COUGH, NO EXPECTORATION.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TOLERATING CLEAR LIQUIDS, POOR APPETITE- ENCOURAGED TO EAT MORE, BUT REFUSED AS WELL AS BEING SLIGHTLY LETHARGIC. FOLEY DRAINING DARK, YELLOW URINE- MARGINAL U/O, 500CC BOLUS X3 GIVEN WITH NO SIGNIFICANT RESPONSE- 40MG IV LASIX GIVEN AT 1800 AND TOLERATED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: PT. GIVEN ONE PERCOCET AND RELIEF FOUND AS WELL AS NO NAUSEA EXPERIENCED.\n\nPLAN: 2, MONITOR SBP, HR AND AFIB, PULMONARY HYGIENE AND PAIN MGT.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-10 00:00:00.000", "description": "Report", "row_id": 1521050, "text": "Nursing Note--B Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. A&Ox3. Answers questions appropriately. Follows commands consistently. MAE in bed.\n\nCARDIAC: Afebrile. HR 90-130 Afib. Started on 25mg Lopressor po with HR >120. 5mg Lopressor IVP x 2 with good effect, HR 80-90's. +PP. Mediastinal and Right Anterior chest tube intact draining serosang fluid.\n\nRESP: LS clear and diminished. Sat 95-98% on RA. Non productive cough.\n\nGI: Abd soft +BS. Tol clears appetite poor.\n\nGU: Foley intact draining qs clear yellow urine.\n\nINTEG: Mediastinal and sternal dressing CDI.\n\nPAIN: 1 perc for pain with good effect.\n\nPSYCH/SOCIAL: Pleasant and cooperative.\n\nPLAN: Possible transfer to 2 today, Monitor UOP, pain, Provide comfort and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-08 00:00:00.000", "description": "Report", "row_id": 1521047, "text": "NEURO: PT. ALERT, ORIENT X3, MAE, OBEYS COMMANDS. PERRL.\n\nCV: PT. AFIB, HR 90-110, PT. HAD BURST OF MD NOTIFIED. 500CCNS BOLUS ORDERED AND GIVEN WITH SLIGHT IMPROVEMENT IN HR. MAG REPLETED AT THIS TIME. DOPAMINE AND NEO RUNNING- CI VIA FICK >3.0, SVO2 70'S- SWAN DC/D. ARTERIAL LINE DAMPENED AND NOT ABLE TO DRAW- FOLLOWING CUFF PRESSURES. DOPAMINE WEANED TO OFF MD , NEO 1.25-1.5MCG TO MAINTAIN SBP >90, MAP >60. CVP 15-13, PA NUMBERS 30'S/20'S.\n\nRESP: PT. CLEAR IN UPPER FIELDS, DIMINISHED IN LOWER LOBES, PT. OXYGENATION >97% ON 2LNC. PT. -COUGH, NO EXPECTORATION. CHEST TUBES X2 TO LWS, NO AIR LEAK NOTED. BOTH DRAINING MINIMAL TO MODERATE SEROSANG DRAINAGE.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TOLERATING CLEAR LIQUIDS, C/O NAUSEA X1 AFTER PERCOCET PO- REGLAND GIVEN AND RELIEF FOUND PER PT. PT U/ MD. NOTIFIED MULTIPLE TIMES. PT. GIVEN ADDITIONAL 500CCNS BOLUS AFTER FIRST BOLUS- WITH NO SIGNIFICANT IMPROVEMENT IN U/O. LYTES REPLETED. FOLEY IRRIGATED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: PT. GIVEN 15MG TORADOL IV AND FOUND RELIEF PER PT. PT. GIVEN 2 PERCOCET 4-6 HOURS WITH MODERATE RELIEF.\n\nPLAN: WEAN NEO, PULMONARY HYGIENE, ADVANCE ACTIVITY AND DIET AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-09 00:00:00.000", "description": "Report", "row_id": 1521048, "text": "Nursing Note--B Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. A&Ox3. Speech clear. Answers questions appropriately. Follows commands consistently. Had brief episode of hallucinating and talking nonsensical after being given ambien. Cleared as night progressed.\n\nCARDIAC: HR 76-113 afib. Had short episodes of RAF with HR as high as 150 lasting 30seconds. MD aware. MAP goal > 65 and SBP goal >90. Neo gtt slowly weaned off. Able to tolerate NEO gtt off x 1 hour. Restarted and will attempt to wean NEO gtt. +PP Right anterior and mediastinal CT intact. Right anterior draining serosang fluid, Mediastinal CT not draining any fluid.\n\nRESP: LS clear and diminished. Sat 97-99% on 2L NC.\n\nGI: ABd soft +BS. Tol clear sips.\n\nGU: Foley intact. Draining less than qs clear yellow urine. MD ordered 40mg Lasix with min effect.\n\nINTEG: Mediastinal and sternal dressing CDI no drainage. Skin CDI.\n\nPSYCH/SOCIAL: Pleasant and cooperative. Slightly anxious at times. Had a brief episode after receiving ambien of hallucinating and being very paranoid. Mood slowly resolved as night progressed. Husband called for update.\n\nPAIN: Toradol d/c'd due to low uop. Morphine 2mg IV with good effect.\n\nPLAN: Wean NEO gtt off as tolerated, Monitor for pain, NEURO and uop, Notify MD RAF, Provide extra reassurance and comfort.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-07 00:00:00.000", "description": "Report", "row_id": 1521042, "text": "hypothermic on arrival w labile bp into the 160's- 170's,some spont. breathing noted w tv's < 80 cc. propofol increased for sedation while warming & morphine given for presumed pain. dopa dc'd on admission for hypertension & huge huo.(intra op lasix).post warming hr generally < 60,afib w occas. pvc's. iv amiodarone held for low rate(usual for patient) & po amiodarone to be started post extubation. remains hemodynamically stable w great svo2 & fick. cvp generally a bit higher than pad ranging from 8 with large diuresis to mid 20's when waking & agitated.propofol off,weakly mae x 4 to command but restless,tachypneic into the 40's with small tv's despite freq. pain medication.discussed w team,resedated with propfol & will reattempt using precedex. family in,husband is designated spokesperson. visitor guidelines reviewed with large extended family,questions answered. seem to understand well.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-07 00:00:00.000", "description": "Report", "row_id": 1521043, "text": "Resp Care\nPt from OR intubated s/p pericardial maze. Current vent settings: CPAP 15/5 50%. Current ABG: 7.32/44/97. Plan is to continue weaning. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-07 00:00:00.000", "description": "Report", "row_id": 1521044, "text": "much improved spont. tv's with calmer demeanor,decreased resp. rate. extubated to open face mask w/o incident. upon extubation c/o severe back pain unrelieved with morphine & position changes. discussed w team,toradol added with significant improvement.remains hemodynamically stable with significantly lower fp's since arrival. gentle hydration given for bp support in the setting of hct > 35%,huge huo & lower fp's.dopa increased from 2->3 for rate & bp support.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-08 00:00:00.000", "description": "Report", "row_id": 1521045, "text": "Neuro: alert and oriented x 3, mae, following commands correctly, unable to get comfortable in bed, c/o lots of back and incisional pain-getting morphine torodol, and started percocets.\n\nCardiac: slow afib with very rare pvc's, continues dopa gtt did start neo gtt for bp, svo2's all wnl's, going by ficks for indexs which have all been wnl's, palpible pedial pulses, skin warm dry and intact, afebrile.\n\nResp: lungs dim in bses, on 3 liters nc satting at 98%, ct systems to lwsxn and both systems with no air leak draining small amounts of serosang.\n\nSkin: chest with dsd that is cdi and has binder on, ct dsd is cdi.\n\nGi/Gu: started sips and tolerating pills, abd is soft round and nontender with hypoactive bowel sounds, blood sugars have been wnl's, u/o > 30/hr.\n\nPlan: ? deline, ? changing pain meds ? diladid, increase activity.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-08 00:00:00.000", "description": "Report", "row_id": 1521046, "text": "Resp Care: Pt exubated last evening without incident. Cuff leak heard prior to extubation. Pt placed on 50% FM-weaned to 3LNC. ABG's WNL.\n" }, { "category": "Echo", "chartdate": "2147-04-07 00:00:00.000", "description": "Report", "row_id": 75319, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial Stripping\nStatus: Inpatient\nDate/Time: at 09:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No mass/thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy.\nModerately dilated RV cavity.\n\nAORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Simple\natheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. Pericardium appears\nthickened. Pericardial calcifications. Echo findings are suggestive but not\ndiagnostic of constriction.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\n1. No mass/thrombus is seen in the left atrium or left atrial appendage.\n2. The right atrium is moderately dilated.\n3. No atrial septal defect is seen by 2D or color Doppler.\n4. Overall left ventricular systolic function is normal (LVEF>55%).\n5. Right ventricular chamber size and free wall motion are normal. The right\nventricular free wall is hypertrophied. There are prominent trebeculations and\na prominent moderator band is seen. The right ventricular cavity is moderately\ndilated. There is 2+ TR.\n6. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta. 7. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. There is no aortic valve\nstenosis. Trace aortic regurgitation is seen.\n8. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is\nseen.\n9. There is a trivial/physiologic pericardial effusion. The pericardium\nappears thickened. There is suggestion of pericardial constriction. There are\npericardial calcifications.\n10. There is mild atheroma in the descending thoracic aorta.\n\n\n" }, { "category": "ECG", "chartdate": "2147-04-07 00:00:00.000", "description": "Report", "row_id": 195375, "text": "Atrial fibrillation with slow ventricular response. Indeterminate frontal\nQRS axis. Right bundle-branch block. Lateral ST-T wave changes are\nnon-specific. Low QRS voltages in precordial leads. Since the previous tracing\nthe voltage is decreased, right bundle-branch block is new and Q-T interval is\nincreased. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2147-04-04 00:00:00.000", "description": "Report", "row_id": 195376, "text": "Atrial fibrillation with bradycardia. Diffuse ST segment depressions and T wave\ninversions in leads I, aVL and V3-V6 which are non-specific. T waves are also\ninverted in lead II. Compared to the previous tracing of ST segment\ndepressions and deepening of T waves have appeared in leads I, aVL, V3-V6.\nT wave inversion has newly appeared in lead aVL. Progressive ST-T wave\nabnormalities. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Echo", "chartdate": "2103-05-24 00:00:00.000", "description": "Report", "row_id": 85054, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Endocarditis.\nHeight: (in) 66\nWeight (lb): 140\nBSA (m2): 1.72 m2\nBP (mm Hg): 120/60\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 15:23\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nNormal PA systolic pressure.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No masses or\nvegetations are seen on the aortic valve, but cannot be fully excluded due to\nsuboptimal image quality. Mild to moderate (+) aortic regurgitation is\nseen. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery\nsystolic pressure is normal.\n\nIMPRESSION: no obvious vegetation seen. There is a small echo density on the\nanterior leaflet of the tricuspid valve (seen best on images #53 and #54) that\nis probably valve thickening but a vegetation cannot be excluded. Mild mitral\nand mild to moderate aortic regurgitation. Preserved regional and global\nbiventricular systolic function.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Echo", "chartdate": "2103-06-08 00:00:00.000", "description": "Report", "row_id": 85052, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 143\nBSA (m2): 1.72 m2\nBP (mm Hg): 133/55\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 16:09\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPropofol was administered by Anesthesia for sedation.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Echocardiographic results were reviewed\nby telephone with the MD caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. There are simple atheroma from the aortic arch to 36 cm distal\nto the incisors in the descending thoracic aorta. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No masses or\nvegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. No mass or vegetation is\nseen on the mitral valve. Trivial mitral regurgitation is seen. No\nvegetation/mass is seen on the pulmonic valve.\n\nCompared with the prior TEE study (images reviewed) of the\nvegetation on the LVOT side of right coronary-cusp leaflet of the aortic valve\n[clip #] is no longer seen and the severity of aortic regurgitation is\nmildly decreased. The other findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2103-05-25 00:00:00.000", "description": "Report", "row_id": 85053, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 143\nBSA (m2): 1.72 m2\nBP (mm Hg): 128/65\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 15:56\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins\nidentified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nAORTA: Simple atheroma in descending aorta. Simple atheroma in abdominal\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Small vegetation on\naortic valve. Mild to moderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. No TEE related complications. The rhythm\nappears to be atrial fibrillation. Echocardiographic results were reviewed by\ntelephone with the MD caring for the patient. Echocardiographic results were\nreviewed by telephone with the houseofficer caring for the patient. Left\npleural effusion.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\nleft ventricular systolic function is normal (LVEF>55%). There are simple\natheroma in the descending thoracic and abdominal aorta. The aortic valve\nleaflets (3) are mildly thickened. A small (3-4mm) mobile echodensity is seen\non the LVOT side of the right coronary leaflet consistent with a vegetation.\nNo abscess is seen. Mild to moderate (+) aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. No mass or vegetation is seen\non the mitral valve. Mild (1+) mitral regurgitation is seen. The septal\nleaflet of the tricuspid valve is minimally thickened but without discrete\nvegetation. No vegetation/mass is seen on the pulmonic valve. There is no\npericardial effusion.\n\nIMPRESSION: Mild echodensity c/w aortic valve vegetation. Mild-moderate aortic\nregurgitation. Mild mitral regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2103-06-08 00:00:00.000", "description": "Report", "row_id": 213497, "text": "Sinus rhythm. Poor R wave progression. Compared to the previous tracing\nof atrial fibrillation is absent and sinus rhythm is now present.\n\n" }, { "category": "ECG", "chartdate": "2103-05-22 00:00:00.000", "description": "Report", "row_id": 213498, "text": "Atrial fibrillation with a rapid ventricular response. Non-specific\nST-T wave changes. Poor R wave progression. Compared to the previous tracing\nof rapid atrial fibrillation and ST-T wave changes are new.\n\n" }, { "category": "ECG", "chartdate": "2103-05-20 00:00:00.000", "description": "Report", "row_id": 213499, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing atrial\nfibrillation is no longer present.\n\n" }, { "category": "Radiology", "chartdate": "2103-05-25 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1073788, "text": " 11:26 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: neesd picc for discharge today\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * PICC W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION *\n * FLUORO GUID PLCT/REPLCT/REMOVE FEE ADJUSTED IN SPECIFIC SITUATION *\n * US GUID FOR VAS. ACCESS FEE ADJUSTED IN SPECIFIC SITUATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with poor venous access\n REASON FOR THIS EXAMINATION:\n neesd picc for discharge today\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KMqd FRI 1:37 PM\n Uncomplicated placement of midline right-sided single-lumen PICC line\n catheter. The tip is in the region of the axillary vein and the catheter is\n ready to use.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: PICC line placement.\n\n PHYSICIANS: Dr. . Dr. was the attending physician who\n reviewed the images.\n\n ANESTHESIA: 5 cc of 1% lidocaine without epinephrine.\n\n TECHNIQUE AND FINDINGS: After the procedure was explained to the patient, the\n patient was brought to the angiography suite and placed in supine position.\n The right upper extremity was prepped and draped in the usual sterile fashion.\n A preprocedure timeout was performed. Next, a micropuncture needle was used\n to access the right brachial vein. A nitinol wire was then passed through the\n needle and into the region of the axillary vein. The needle was removed and a\n micropuncture sheath was then placed over the wire. As difficulty in\n negotiating past the region of the axilla was encountered, contrast was\n injected which demonstrated tortuosity in the region of the wire, although\n contrast did flow freely into the central venous system. Multiple attempts\n were made at negotiating past this focal region of tortuosity unsuccessfully.\n It was decided to leave a midline line catheter at this point for antibiotic\n therapy.\n\n The micropuncture sheath was then removed and a 21 length single lumen midline\n catheter, was positioned over the wire with the tip at the level of the\n axillary vein. The wire was removed and the catheter was aspirated and\n flushed. The catheter was secured in place. A sterile dressing was applied.\n\n The patient tolerated the patient tolerated the procedure well without\n immediate complication.\n\n IMPRESSION:\n\n (Over)\n\n 11:26 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: neesd picc for discharge today\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Uncomplicated placement of midline right-sided single-lumen catheter with the\n tip at the level of the axillary vein. The catheter is ready to use.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2103-05-25 00:00:00.000", "description": "FEE ADJUSTED IN SPECIFIC SITUATION", "row_id": 1073789, "text": ", C. GU 12R 11:26 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: neesd picc for discharge today\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with poor venous access\n REASON FOR THIS EXAMINATION:\n neesd picc for discharge today\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated placement of midline right-sided single-lumen PICC line\n catheter. The tip is in the region of the axillary vein and the catheter is\n ready to use.\n\n" }, { "category": "Nursing", "chartdate": "2103-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568158, "text": "Patient is s a 69 y/o F with was admitted to general surgery\n for presumptive PSBO and fevers after transfer from .\n Further work-up identified no PSBO. Patient's inital CT abdomen at\n identified non-obstructing bilateral renal stones without\n evidence of pyelonephritis. Patient had spiked temp to 101.5 on \n and had worsening flank pain (L> R). CT abdomen was performed again\n and showed obstructing L ureteral 7mm stone and was transferred to\n urology service. Patient had a L ureteral stent placed and\n developed AFib with RVR post operatively.\n .\n Patient had afib with RVR preop but went to procedure. Post op,\n patient received 12.5 PO lopressor x 1 and SBP 90-100s. Patient also\n was started on esmolol gtt which dropped pressures to SBP 70s.\n .\n Patient was transferred to the for further monitoring. Patient\n complains of some mild abd pain post procedurally, but denies N, V, D,\n CP, SOB.\n On arrival to unit pt hr 150\ns a-fib, was given 10mg of dilt. Iv push\n then dilt gtt was started and it is now at 10mg/hr. Hr 110-120\n still in a-fiib.\n Plan: continue to watch overnight until HR is in better control.\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568221, "text": "69 y/o F with a history of A-Fib who is s/p L ureteral stent placement\n r/t renal stone with drainage of frank pus on . She developed AFib\n with RVR post operatively. Pt was transferred to M/SICU. On arrival to\n unit pts HR was 150\ns a-fib, received bolus dose of IV diltiazem and\n started on diltiazem drip.\n Sepsis without organ dysfunction\n Assessment:\n Pts temp up to 102.9 at 8 PM.\n BP down from 120\ns -> 80\ns systolic.\n Urine output 30-100cc/hr.\n 02 sats 92-97% on 2L NC, LS clear bilat.\n Green bilious stool draining from ostomy.\n CVP 13-17.\n Action:\n Received 1 L IVF bolus, dilaudid pca dose reduced.\n Received 650mg Tylenol.\n No further cultures ordered as pt was already pan-cultured.\n On IV abx as ordered.\n Response:\n BP improved following IVF bolus and reduction in PCA dose.\n Temp down to 97.7 following Tylenol, cool bath.\n UO remains adequate.\n Plan:\n Cont to closely monitor pts vitals, urine output, resp status.\n f/u with previous cultures.\n Atrial fibrillation (Afib)\n Assessment:\n At start of shift pts HR 110-130 AF on 15mg/hr of diltiazem.\n Action:\n Received 60mg dose of PO diltiazem at 8 PM.\n Response:\n HR down to 70-80\ns a-fib and drip titrated off at 10 PM.\n Plan:\n Cont to monitor pts HR.\n Administer PO diltiazem as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n At start of shift pt c/o pain in left flank.\n Little to no relief noted by pt following PCA injections.\n Action:\n MD team made aware of poor pain control.\n Received bolus of 0.5mg dilaudid.\n PCA dose increased.\n Response:\n Pt stated improvement of pain to following increase in dilaudid\n PCA dose.\n Pts became more lethargic, SBP down to 80-90\n Plan:\n PCA dose reduced back to original levels.\n Pts BP improved following reduction in pain meds.\n Pt sleeping comfortably at present.\n Cont to monitor pts pain level.\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568222, "text": "69 y/o F with a history of A-Fib who is s/p L ureteral stent placement\n r/t renal stone with drainage of frank pus on . She developed AFib\n with RVR post operatively. Pt was transferred to M/SICU. On arrival to\n unit pts HR was 150\ns a-fib, received bolus dose of IV diltiazem and\n started on diltiazem drip.\n Sepsis without organ dysfunction\n Assessment:\n Pts temp up to 102.9 at 8 PM.\n BP down from 120\ns -> 80\ns systolic.\n Urine output 30-100cc/hr.\n 02 sats 92-97% on 2L NC, LS clear bilat.\n Green bilious stool draining from ostomy.\n CVP 13-17.\n Action:\n Received 1 L IVF bolus, dilaudid pca dose reduced.\n Received 650mg Tylenol.\n No further cultures ordered as pt was already pan-cultured.\n On IV abx as ordered.\n Ostomy appliance changed.\n Response:\n BP improved following IVF bolus and reduction in PCA dose.\n Temp down to 97.7 following Tylenol, cool bath.\n UO remains adequate.\n Plan:\n Cont to closely monitor pts vitals, urine output, resp status.\n f/u with previous cultures.\n Atrial fibrillation (Afib)\n Assessment:\n At start of shift pts HR 110-130 AF on 15mg/hr of diltiazem.\n Action:\n Received 60mg dose of PO diltiazem at 8 PM.\n Response:\n HR down to 70-80\ns a-fib and drip titrated off at 10 PM.\n Plan:\n Cont to monitor pts HR.\n Administer PO diltiazem as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n At start of shift pt c/o pain in left flank.\n Little to no relief noted by pt following PCA injections.\n Action:\n MD team made aware of poor pain control.\n Received bolus of 0.5mg dilaudid.\n PCA dose increased.\n Response:\n Pt stated improvement of pain to following increase in dilaudid\n PCA dose.\n Pts became more lethargic, SBP down to 80-90\n Plan:\n PCA dose reduced back to original levels.\n Pts BP improved following reduction in pain meds.\n Pt sleeping comfortably at present.\n Cont to monitor pts pain level.\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568223, "text": "69 y/o F with a history of A-Fib and total colectomy with illiostomy\n who is s/p L ureteral stent placement r/t renal stone with drainage of\n frank pus on . She developed AFib with RVR post operatively. Pt was\n transferred to M/SICU. On arrival to unit pts HR was 150\ns a-fib,\n received bolus dose of IV diltiazem and started on diltiazem drip.\n Sepsis without organ dysfunction\n Assessment:\n Pts temp up to 102.9 at 8 PM.\n BP down from 120\ns -> 80\ns systolic.\n Urine output 30-100cc/hr.\n 02 sats 92-97% on 2L NC, LS clear bilat.\n Green bilious stool draining from ostomy.\n CVP 13-17.\n Action:\n Received 1 L IVF bolus, dilaudid pca dose reduced.\n Received 650mg Tylenol.\n No further cultures ordered as pt was already pan-cultured.\n On IV abx as ordered.\n Ostomy appliance changed.\n Response:\n BP improved following IVF bolus and reduction in PCA dose.\n Temp down to 97.7 following Tylenol, cool bath.\n UO remains adequate.\n Plan:\n Cont to closely monitor pts vitals, urine output, resp status.\n f/u with previous cultures.\n Atrial fibrillation (Afib)\n Assessment:\n At start of shift pts HR 110-130 AF on 15mg/hr of diltiazem.\n Action:\n Received 60mg dose of PO diltiazem at 8 PM.\n Response:\n HR down to 70-80\ns a-fib and drip titrated off at 10 PM.\n Plan:\n Cont to monitor pts HR.\n Administer PO diltiazem as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n At start of shift pt c/o pain in left flank.\n Little to no relief noted by pt following PCA injections.\n Action:\n MD team made aware of poor pain control.\n Received bolus of 0.5mg dilaudid.\n PCA dose increased.\n Response:\n Pt stated improvement of pain to following increase in dilaudid\n PCA dose.\n Pts became more lethargic, SBP down to 80-90\n Plan:\n PCA dose reduced back to original levels.\n Pts BP improved following reduction in pain meds.\n Pt sleeping comfortably at present.\n Cont to monitor pts pain level.\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568224, "text": "69 y/o F with a history of A-Fib and total colectomy with illiostomy\n who is s/p L ureteral stent placement r/t renal stone with drainage of\n frank pus on . She developed AFib with RVR post operatively. Pt was\n transferred to M/SICU. On arrival to unit pts HR was 150\ns a-fib,\n received bolus dose of IV diltiazem and started on diltiazem drip.\n Sepsis without organ dysfunction\n Assessment:\n Pts temp up to 102.9 at 8 PM.\n BP down from 120\ns -> 80\ns systolic.\n Urine output 30-100cc/hr.\n 02 sats 92-97% on 2L NC, LS clear bilat.\n Green bilious stool draining from ostomy.\n CVP 13-17.\n Action:\n Received 1 L IVF bolus, dilaudid pca dose reduced.\n Received 650mg Tylenol.\n No further cultures ordered as pt was already pan-cultured.\n On IV abx as ordered.\n Ostomy appliance changed.\n Response:\n BP improved following IVF bolus and reduction in PCA dose.\n Temp down to 97.7 following Tylenol, cool bath.\n UO remains adequate.\n Plan:\n Cont to closely monitor pts vitals, urine output, resp status.\n f/u with previous cultures.\n Atrial fibrillation (Afib)\n Assessment:\n At start of shift pts HR 110-130 AF on 15mg/hr of diltiazem.\n Action:\n Received 60mg dose of PO diltiazem at 8 PM.\n Response:\n HR down to 70-80\ns a-fib and drip titrated off at 10 PM.\n 0200 diltiazem dose held r/t SBP 90-100 (MD aware)\n Plan:\n Cont to monitor pts HR.\n Administer PO diltiazem as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n At start of shift pt c/o pain in left flank.\n Little to no relief noted by pt following PCA injections.\n Action:\n MD team made aware of poor pain control.\n Received bolus of 0.5mg dilaudid.\n PCA dose increased.\n Response:\n Pt stated improvement of pain to following increase in dilaudid\n PCA dose.\n Pts became more lethargic, SBP down to 80-90\n Plan:\n PCA dose reduced back to original levels.\n Pts BP improved following reduction in pain meds.\n Pt sleeping comfortably at present.\n Cont to monitor pts pain level.\n" }, { "category": "Physician ", "chartdate": "2103-05-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 568149, "text": "TITLE:\n Chief Complaint: Afib w/ RVR, s/p L Ureteral Placement\n HPI:\n Patient is s a 69 y/o F with was admitted to general surgery\n for presumptive pSBO and fevers after transfer from .\n Further work-up identified no pSBO. Patient's inital CT abdomen at\n identified non-obstructing bilateral renal stones without\n evidence of pyelonephritis. Patient had spiked temp to 101.5 on \n and had worsening flank pain (L> R). CT abdomen was performed again\n and showed obstructing L ureteral 7mm stone and was transferred to\n urology service. Patient had a L ureteral placed and\n developed AFib with RVR post operatively.\n .\n Patient had afib with RVR preop but went to procedure. Post op,\n patient received 12.5 PO lopressor x 1 and SBP 90-100s. Patient also\n was started on esmolol gtt which dropped pressures to SBP 70s.\n .\n Patient was transferred to the for further monitoring. Patient\n complains of some mild abd pain post procedurally, but denies N, V, D,\n CP, SOB.\n Allergies:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:08 PM\n Infusions:\n Diltiazem - 10 mg/hour\n Other ICU medications:\n Diltiazem - 01:20 PM\n Other medications:\n MEDICATIONS AT TRANSFER:\n Acetaminophen 325-650 mg PO Q6H:PRN\n Metoprolol Tartrate 12.5 mg PO Q6H\n Cepacol (Menthol) 1 LOZ PO PRN sore throat\n Ondansetron 4 mg IV Q8H:PRN nausea\n Pantoprazole 40 mg IV Q24H Order date: @ 0810\n Piperacillin-Tazobactam Na 2.25 g IV Q6H\n HYDROmorphone (Dilaudid) 0.5 mg IV Q3H\n HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes\n Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s)\n Heparin 5000 UNIT SC TID\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n - ulcerative colitis\n - s/p total colectomy at age 24\n - multiple bowel obstructions adhesions\n - nephrolithiasis\n - ventral hernia\n - osteoarthritis\n - endometriosis s/p hysterectomy\n - PAF - was on coumadin x2 yrs, but this was dc'ed 4mo ago by\n her cardiologist\n - h/o alcoholism - sober x 20 years\n .\n PAST SURGICAL HISTORY:\n - total colectomy at age 24\n - 18 laparotomies\n - ex-lap\n - hysterectomy\n - intestinal plication\n - ventral hernia repair\n - bilateral total knee replacement\n - left total hip replacement\n - tonsillectomy\n - appendectomy\n No family members with /Crohns or other GI disease\n Retired social worker. in ADL's, walks with walker at\n baseline. Widowed x 9 years. Has son and daughter. denies tobacco.\n Recovering alcoholic, sober x20 years. Denies drug abuse.\n Review of systems:\n Flowsheet Data as of 04:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 125 (125 - 144) bpm\n BP: 126/61(79) {121/61(76) - 139/86(99)} mmHg\n RR: 28 (19 - 28) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 13 (13 - 13)mmHg\n Total In:\n 3,468 mL\n PO:\n TF:\n IVF:\n 1,168 mL\n Blood products:\n Total out:\n 0 mL\n 605 mL\n Urine:\n 315 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,863 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n GENERAL - NAD, appropriate\n HEENT - PERRLA, EOMI, dry MM, OP clear\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh,\n HEART - PMI non-displaced, RRR, no MRG, nl S1-S2\n ABDOMEN - soft, Generalized TTP/ND, no rebound/guarding, ostomy in\n place.\n EXTREMITIES - WWP, no c/c/e,\n SKIN - no rashes or lesions\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 5/5\n throughout, sensation grossly intact throughout, DTRs 2+ and symmetric,\n cerebellar exam intact, steady gait\n Labs / Radiology\n [image002.jpg]\n CT abd: low grad pSBO from adhesions about RLQ ostomy & ant abd\n inc. Mildly dilated loops Bowel in mid or distal jejunum w/ most\n severly angulated loop of bowel just distal to adjacent ileostomy. 7mm\n L renal calculus w/in renal pelvis, non-obstructing, no hydronephrosis,\n b/l renal scarring, 6mm nodular opacity in R middle lobe along the\n major fissure\n .\n : CT Abd: Obstructing calculus in the left UPJ, causing\n moderate hydronephrosis.\n PFI: Obstructing stone in the left mid ureter, measuring roughly 7-mm\n in the greatest dimension. This causes moderate hydronephrosis.\n Multiple stones in the right kidney as well, with mild fullness of the\n collecting system. This is stable from the previous exam.\n Assessment and Plan\n 69 y/o F with a history of PAF (off anticoagulation) who is s/p L\n ureteral placement who developed AFib with RVR post operatively\n and was traniently hypotensive.\n .\n #. Afib with RVR: Patient currently hemodynamically stable.\n Ventricular rates currently 110-120s. Patient does have a history of\n PAF and is currently off anticoagulation. CHADS2 is 0, or 1 if using\n age > 65. Patient would benefit from ASA therapy. No echocardiogram\n in our system, no evidence of heart failure on examination. Patient\n had transient hypotension to beta blockers, will attempt to rate\n control with diltiazem bolus with drip.\n - Bolus Diltiazem 5mg IV x 1; start dilt gtt at 5mg and titrate upward\n for HR < 80 and SBP > 100.\n - Defer anticoagulation for now, will consider starting ASA 325mg\n - PRN NS Boluses\n - EKG in AM\n - Monitor on telemetry\n .\n #. SIRS/Left obstructed pyelonephritis: Patient is s/p L ureteral\n placement for obstructing stone. Frank pus drained after\n procedure, gram stain negative, showed PMNs. Pt has been on abx.\n Patient was febrile and had RR > 30 intermittantly. CVP is 14.\n Evidence of hydronephrosis on CT scan. At this point, UA has been\n negative and BCx have shown NGTD. Patient is currently afebrile,\n however previously had WBC to 12.8 and has continued to spike Temp\n overnight. Patient's last temp was 102.9 on at 9:30pm. Patient\n currently on Zosyn. Of note, patient had an admission one month ago\n for pyelonephritis and was treated with a course of ciprofloxacin.\n - Continue Zosyn for now\n - Check VBG and MVO2\n - Goal CVP > 10, MAP > 65\n - Follow up Urine and Blood Cx\n - Pain control with Dilaudid PCA\n .\n #. Acute renal sufficiency: Cr 1.8. B/l < 1.0. Likely post\n obstructive renal failure. As patient is s/p ureteral , \n monitor to see resolution in Cr. Patient still has stone, will likely\n pass with placement of .\n - Trend Cr\n - Monitor UOP\n - Renally dose medications\n .\n #. FEN - NPO for now\n .\n #. Access - PIV, R Sublclavian\n .\n #. PPx -\n -DVT ppx with SQ Heparin and PPI\n -Bowel regimen\n -Pain management with Dlaudid PCA\n .\n #. Code - full code\n .\n #. Dispo - Pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2103-05-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 568145, "text": "Chief Complaint: Hypotension in setting of atrial fibrillation with\n rapid ventricular rate and urosepsis.\n HPI:\n 69yo with Hx UC s/p colectomy and renal nephrolithiasis admit to \n for hypotension, Afib RVR s/p placement of L. ureteral stent, with\n drainage of frank pus.\n Patient Hx dates to when she was admitted to for fever,\n suprapubic abd pain, and evidence of dehydration. She underwent a CT\n Abdomen which showed several renal stones, the largest 7mm. A renal US\n showed larger 12-13mm calculi, without hydronephrosis. UCx positive for\n E.coli and she was treated with Ciprofloxacin. The patient f/u as outpt\n and plan was surgical intervention. However, patient developed abd\n pain and fever to 101F; she was admitted to where she was\n found to be in ARF (Cr 0.7-->1.7). A CT Abd (I+) notable for ? partial\n SBO; no evidence of pylenephritis, obstructing stones or perinephric\n abscess; she was txferred to . On pt developed a fever to\n 101.5F and L. flank pain; a repeat CT positive for a left 7mm\n obstructing ureteral stone. As such on she underwent a\n ureteroscopy with placement of a stent; this was associated with\n release of frank pus. In this setting patient developed Afib with RVR\n (HR=150). She wa started on Zosyn and given Esmolol for rate control,\n though with a drop in her BP= 70/30. Given this hyotension she was\n transferred to the .\n Currently pt c/o L. flank pain, sharp, , nnon-radiating. Also c/o\n R. knee pain, sharp non-radiating (Hx OA). Denies n/v, abd pain. Denies\n chest pain, palpitations, dyspnea, cough, sputum production.\n Patient admitted from: OR / PACU\n History obtained from Patient\n Allergies:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:08 PM\n Infusions:\n Other ICU medications:\n Diltiazem - 01:20 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - Paroxysmal atrial fibrillation, not currently on anticoagulation\n - UC s/p colectomy, with ileostomy\n - Hx SBO though adhesions\n - Osteoarthritis\n - s/p hysterectomy\n - s/p appendectomy\n - former Alcoholic, now sober\n NC\n Occupation: Social worker, retired\n Drugs: none\n Tobacco: none\n Alcohol: former user,\n Other:\n Review of systems:\n Flowsheet Data as of 02:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 132 (126 - 144) bpm\n BP: 139/67(82) {134/67(82) - 139/86(99)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,417 mL\n PO:\n TF:\n IVF:\n 1,117 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,092 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n FiO2: 5L NC\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Thin, Tachypneic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), Tachycardic. No m/r/g\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : )\n Abdominal: Soft, Bowel sounds present, stoma pink.\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): AOx3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n EKG= irreg irreg, rate=120. Normal axis, no ST changes.\n CT Abd= L. calyx dilatation. No perinephric abscess.\n Assessment and Plan\n 69yo with Hx nephrolithiasis, UC, pAF, now in RVR following stent\n placement for ureteral obstruction.\n Meets criteria for sepsis. Hypotensive in setting of sepsis and RVR.\n Hypoxemic.\n 1. Sepsis ureteral obstruction.\n - Infection source now managed --> s/p placement of ureteral stent.\n Urology team following.\n - Will follow up blood and urine cultures and sensitivities.\n - Currently on Zosyn for presumed GNR coverage. Less likely that\n this is due to gram positive organism.\n - Fluid resuscitate to CVP=, though this will be balanced by\n development of pulmonary edema diastolic dysfunction\n - MAPs >65\n - Will check ScvO2, goal >70%\n - f/u urine output\n 2. Afib with RVR\n - Likely provoked by infection. EKG sans evidence of ACS\n - Rate control with diltiazem; goal HR~80\n - Would initiate anti-platelet therapy; CHADS2= 0, so\n anticoagulation not highly indicated; TTe may be helpful to see if she\n has developed a L. atrial thrombus.\n - Will balance rate control with maintaining adequate blood\n pressures; if unable to maintain pressures can consider\n cardioversion, though certainly this has risks of thromboemboli\n formation / CVA (given Hx pAF); cardioversion might also\n have limited success given this is pAF\n 3. Hypoxemia-\n - Likely secondary to edema (given RVR), perhaps atelectasis.\n Unlikely R\nL shunt\n - Will obtain pCXR to r/o pna\n - Keep SpO2>92%\n 3. Acute renal failure\n - likely secondary to obstruction, though could have a pre-renal\n etiology / ATN as well. Cannot exclude AIN given she has\n been on peniciliin agents.\n - Will monitor urine output.\n - Bolus fluid to keep CVP 8-12 as above\n - Renally dose medications and remove offending agents.\n - No indication for RRT currently.\n - urine acidified, to prevent further nephrolithiasis\n formation.\n 4. Acid- base status\n - Chem 7 c/w non-gap hyperchloremic metabolic acidosis. Can check\n urine electrolytes.\n - Limit exogenous Cl (use D5W with bicarb to resuscitate)\n - Patient is tachypneic (approp compensatory response), but doesn;t\n appear to be tiring.\n - Can keep an eye on VBGs obtained through central line.\n 5. Thrombocytopenia\n - Likely infection. Will follow.\n - Check coags to help r/o DIC; if plts decrease can check\n fibrinogen, split dimer products.\n - Pattern not consistent with HIT, no evidence TTP/HUS.\n 6. Pain\n - Dilaudid PCA for flank pain.\n 7. ICU Issues\n - Diet= clear, advance as tolerated\n - Access= R. IJ TLC. If becomes more hypotensive, may need\n arterial line. Currently no indication.\n - Full Code (d/w patient)\n - Prophylaxis\n + DVT= SQ heparin, SCDs/TEDS\n + Bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:53 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "General", "chartdate": "2103-05-23 00:00:00.000", "description": "Generic Note", "row_id": 568306, "text": "TITLE:\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568317, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n 69 y/o F with a history of A-Fib and total colectomy with illiostomy\n who is s/p L ureteral stent placement r/t renal stone with drainage of\n frank pus on . She developed AFib with RVR post operatively. Pt was\n transferred to M/SICU. On arrival to unit pts HR was 150\ns a-fib,\n received bolus dose of IV diltiazem and started on diltiazem drip.\n" }, { "category": "Physician ", "chartdate": "2103-05-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 568166, "text": "Chief Complaint: Hypotension in setting of atrial fibrillation with\n rapid ventricular rate and urosepsis.\n HPI:\n 69yo with Hx UC s/p colectomy and renal nephrolithiasis admit to \n for hypotension, Afib RVR s/p placement of L. ureteral stent, with\n drainage of frank pus.\n Patient Hx dates to when she was admitted to for fever,\n suprapubic abd pain, and evidence of dehydration. She underwent a CT\n Abdomen which showed several renal stones, the largest 7mm. A renal US\n showed larger 12-13mm calculi, without hydronephrosis. UCx positive for\n E.coli and she was treated with Ciprofloxacin. The patient f/u as outpt\n and plan was surgical intervention. However, patient developed abd\n pain and fever to 101F; she was admitted to where she was\n found to be in ARF (Cr 0.7-->1.7). A CT Abd (I+) notable for ? partial\n SBO; no evidence of pylenephritis, obstructing stones or perinephric\n abscess; she was txferred to . On pt developed a fever to\n 101.5F and L. flank pain; a repeat CT positive for a left 7mm\n obstructing ureteral stone. As such on she underwent a\n ureteroscopy with placement of a stent; this was associated with\n release of frank pus. In this setting patient developed Afib with RVR\n (HR=150). She wa started on Zosyn and given Esmolol for rate control,\n though with a drop in her BP= 70/30. Given this hyotension she was\n transferred to the .\n Currently pt c/o L. flank pain, sharp, , nnon-radiating. Also c/o\n R. knee pain, sharp non-radiating (Hx OA). Denies n/v, abd pain. Denies\n chest pain, palpitations, dyspnea, cough, sputum production.\n Patient admitted from: OR / PACU\n History obtained from Patient\n Allergies:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:08 PM\n Infusions:\n Other ICU medications:\n Diltiazem - 01:20 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - Paroxysmal atrial fibrillation, not currently on anticoagulation\n - UC s/p colectomy, with ileostomy\n - Hx SBO though adhesions\n - Osteoarthritis\n - s/p hysterectomy\n - s/p appendectomy\n - former Alcoholic, now sober\n NC\n Occupation: Social worker, retired\n Drugs: none\n Tobacco: none\n Alcohol: former user,\n Other:\n Review of systems:\n Flowsheet Data as of 02:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 132 (126 - 144) bpm\n BP: 139/67(82) {134/67(82) - 139/86(99)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,417 mL\n PO:\n TF:\n IVF:\n 1,117 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,092 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n FiO2: 5L NC\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Thin, Tachypneic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), Tachycardic. No m/r/g\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : )\n Abdominal: Soft, Bowel sounds present, stoma pink.\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): AOx3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 127\n 29\n 120\n 1.5\n 17\n 20\n 114\n 3.7\n 137\n 6\n [image002.jpg]\n EKG= irreg irreg, rate=120. Normal axis, no ST changes.\n CT Abd= L. calyx dilatation. No perinephric abscess.\n Assessment and Plan\n 69yo with Hx nephrolithiasis, UC, pAF, now in AF c RVR following stent\n placement for ureteral obstruction.\n Meets criteria for sepsis. Hypotensive in setting of sepsis and RVR.\n Hypoxemic.\n 1. Sepsis ureteral obstruction.\n - Infection source now managed --> s/p placement of ureteral stent.\n Urology team following.\n - Will follow up blood and urine cultures and sensitivities.\n - Currently on Zosyn for presumed GNR coverage. Less likely that\n this is due to gram positive organism.\n - Fluid resuscitate to CVP=, though this will be balanced by\n development of pulmonary edema diastolic dysfunction\n - MAPs >65\n - Will check ScvO2, goal >70%\n - f/u urine output, consider f/u USG if she remains febrile\n 2. AF with RVR\n - Likely provoked by infection and relative hypovolemia. EKG\n without evidence of ACS\n - Rate control with diltiazem; goal HR~80\n - Would initiate anti-platelet therapy; CHADS2= 0, so\n anticoagulation not highly indicated; TTe may be helpful to see if she\n has developed a L. atrial thrombus.\n - Will balance rate control with maintaining adequate blood\n pressures; if unable to maintain pressures can consider\n cardioversion, though certainly this has risks of thromboemboli\n formation / CVA (given Hx pAF); cardioversion might also\n have limited success given this is pAF\n 3. Hypoxemia-\n - Likely secondary to edema (given RVR), perhaps atelectasis.\n Unlikely R\nL shunt\n - Will obtain pCXR to r/o pna\n - Keep SpO2>92%\n 3. Acute renal failure\n - likely secondary to obstruction, though could have a pre-renal\n etiology / ATN as well. Cannot exclude AIN given she has\n been on peniciliin agents.\n - Will monitor urine output.\n - Bolus fluid to keep CVP 8-12 as above\n - Renally dose medications and remove offending agents.\n - No indication for RRT currently.\n - urine acidified, to prevent further nephrolithiasis\n formation.\n 4. Acid- base status\n - Chem 7 c/w non-gap hyperchloremic metabolic acidosis. Can check\n urine electrolytes.\n - Limit exogenous Cl (use D5W with bicarb to resuscitate)\n - Patient is tachypneic (approp compensatory response), but doesn;t\n appear to be tiring.\n - Can keep an eye on VBGs obtained through central line.\n 5. Thrombocytopenia\n - Likely infection. Will follow.\n - Check coags to help r/o DIC; if plts decrease can check\n fibrinogen, split dimer products.\n - Pattern not consistent with HIT, no evidence TTP/HUS.\n 6. Pain\n - Dilaudid PCA for flank pain.\n 7. ICU Issues\n - Diet= clear, advance as tolerated\n - Access= R. IJ TLC. If becomes more hypotensive, may need\n arterial line. Currently no indication.\n - Full Code (d/w patient)\n - Prophylaxis\n + DVT= SQ heparin, SCDs/TEDS\n + Bowel regimen\n Patient is critically ill\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2103-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568160, "text": "Patient is s a 69 y/o F with was admitted to general surgery\n for presumptive PSBO and fevers after transfer from .\n Further work-up identified no PSBO. Patient's inital CT abdomen at\n identified non-obstructing bilateral renal stones without\n evidence of pyelonephritis. Patient had spiked temp to 101.5 on \n and had worsening flank pain (L> R). CT abdomen was performed again\n and showed obstructing L ureteral 7mm stone and was transferred to\n urology service. Patient had a L ureteral stent placed and\n developed AFib with RVR post operatively.\n .\n Patient had afib with RVR preop but went to procedure. Post op,\n patient received 12.5 PO lopressor x 1 and SBP 90-100s. Patient also\n was started on esmolol gtt which dropped pressures to SBP 70s.\n .\n Patient was transferred to the for further monitoring. Patient\n complains of some mild abd pain post procedurally, but denies N, V, D,\n CP, SOB.\n On arrival to unit pt hr 150\ns a-fib, was given 10mg of dilt. Iv push\n then dilt gtt was started and it is now at 10mg/hr. Hr 110-120\n still in a-fiib.\n Plan: continue to watch overnight until HR is in better control.\n" }, { "category": "Physician ", "chartdate": "2103-05-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 568137, "text": "Chief Complaint: Hypotension in setting of atrial fibrillation with\n rapid ventricular rate and urosepsis.\n HPI:\n 69yo with Hx UC s/p colectomy and renal nephrolithiasis admit to \n for hypotension, Afib RVR s/p placement of L. ureteral stent, with\n drainage of frank pus.\n Patient Hx dates to when she was admitted to for fever,\n suprapubic abd pain, and evidence of dehydration. She underwent a CT\n Abdomen which showed several renal stones, the largest 7mm. A renal US\n showed larger 12-13mm calculi, without hydronephrosis. UCx positive for\n E.coli and she was treated with Ciprofloxacin. The patient f/u as outpt\n and plan was surgical intervention. However, patient developed abd\n pain and fever to 101F; she was admitted to where she was\n found to be in ARF (Cr 0.7-->1.7). A CT Abd (I+) notable for ? partial\n SBO; no evidence of pylenephritis, obstructing stones or perinephric\n abscess; she was txferred to . On pt developed a fever to\n 101.5F and L. flank pain; a repeat CT positive for a left 7mm\n obstructing ureteral stone. As such on she underwent a\n ureteroscopy with placement of a stent; this was associated with\n release of frank pus. In this setting patient developed Afib with RVR\n (HR=150). She wa started on Zosyn and given Esmolol for rate control,\n though with a drop in her BP= 70/30. Given this hyotension she was\n transferred to the .\n Currently pt c/o L. flank pain, sharp, , nnon-radiating. Also c/o\n R. knee pain, sharp non-radiating (Hx OA). Denies n/v, abd pain. Denies\n chest pain, palpitations, dyspnea, cough, sputum production.\n Patient admitted from: OR / PACU\n History obtained from Patient\n Allergies:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:08 PM\n Infusions:\n Other ICU medications:\n Diltiazem - 01:20 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - Paroxysmal atrial fibrillation, not currently on anticoagulation\n - UC s/p colectomy, with ileostomy\n - Hx SBO though adhesions\n - Osteoarthritis\n - s/p hysterectomy\n - s/p appendectomy\n - former Alcoholic, now sober\n NC\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: former user,\n Other:\n Review of systems:\n Flowsheet Data as of 02:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 132 (126 - 144) bpm\n BP: 139/67(82) {134/67(82) - 139/86(99)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,417 mL\n PO:\n TF:\n IVF:\n 1,117 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,092 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n FiO2: 5L NC\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Thin, Tachypneic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), Tachycardic. No m/r/g\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : )\n Abdominal: Soft, Bowel sounds present, stoma pink.\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): AOx3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 69yo with Hx nephrolithiasis, UC, pAF, now in RVR following stent\n placement for ureteral obstruction.\n Meets criteria for sepsis. Hypotensive in setting of sepsis and RVR.\n Hypoxemic.\n 1. Sepsis ureteral obstruction.\n - Infection source now managed --> s/p placement of ureteral stent.\n Urology team following.\n - Will follow up blood and urine cultures and sensitivities.\n - Currently on Zosyn for presumed GNR coverage. Less likely that\n this is due to gram positive organism.\n - Fluid resuscitate to CVP=, though this will be balanced by\n development of pulmonary edema diastolic dysfunction\n - MAPs >65\n - Will check ScvO2, goal >70%\n 2. Afib with RVR\n - Likely provoked by infection. EKG sans evidence of ACS\n - Rate control with diltiazem; goal HR~80\n - Would initiate anti-platelet therapy; CHADS2= 0, so\n anticoagulation not highly indicated; TTe may be helpful to see if she\n has developed a L. atrial thrombus.\n - Will balance rate control with maintaining adequate blood\n pressures; if unable to maintain pressures can consider cardioversion,\n though certainly this has risks of thromboemboli formation / CVA, given\n Hx pAF.\n 3. Hypoxemia-\n - Likely secondary to edema (given RVR), perhaps atelectasis.\n Unlikely R\nL shunt\n - Will obtain pCXR to r/o pna\n - Keep SpO2>92%\n 3. Acute renal failure\n - likely secondary to obstruction, though could have a pre-renal\n etiology / ATN as well. Cannot exclude AIN given she has been on\n peniciliin agents.\n - Will monitor urine output.\n - Bolus fluid to keep CVP 8-12 as above\n - Renally dose medications and remove offending agents.\n - No indication for RRT currently.\n - urine acidified, to prevent further nephrolithiasis\n formation.\n 4. Acid- base status\n - Chem 7 c/w non-gap metabolic acidosis. Likely RTA. Can check\n urine electrolytes.\n - Patient is tachypneic (approp compensatory response), but doesn;t\n appear to be tiring.\n - Can keep an eye on VBGs obtained through central line.\n 5. Thrombocytopenia\n - Likely infection. Will follow.\n - Check coags to help r/o DIC; if plts decrease can check\n fibrinogen, split dimer products.\n - Pattern not consistent with HIT, no evidence TTP/HUS.\n 6. ICU Issues\n - Diet= clear, advance as tolerated\n - Access= R. IJ TLC. If becomes more hypotensive, may need\n arterial line. Currently no indication.\n - Full Code (d/w patient)\n - Prophylaxis\n + DVT= SQ heparin, SCDs/TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:53 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2103-05-22 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 568139, "text": "Chief Complaint: Hypotension in setting of atrial fibrillation with\n rapid ventricular rate and urosepsis.\n HPI:\n 69yo with Hx UC s/p colectomy and renal nephrolithiasis admit to \n for hypotension, Afib RVR s/p placement of L. ureteral stent, with\n drainage of frank pus.\n Patient Hx dates to when she was admitted to for fever,\n suprapubic abd pain, and evidence of dehydration. She underwent a CT\n Abdomen which showed several renal stones, the largest 7mm. A renal US\n showed larger 12-13mm calculi, without hydronephrosis. UCx positive for\n E.coli and she was treated with Ciprofloxacin. The patient f/u as outpt\n and plan was surgical intervention. However, patient developed abd\n pain and fever to 101F; she was admitted to where she was\n found to be in ARF (Cr 0.7-->1.7). A CT Abd (I+) notable for ? partial\n SBO; no evidence of pylenephritis, obstructing stones or perinephric\n abscess; she was txferred to . On pt developed a fever to\n 101.5F and L. flank pain; a repeat CT positive for a left 7mm\n obstructing ureteral stone. As such on she underwent a\n ureteroscopy with placement of a stent; this was associated with\n release of frank pus. In this setting patient developed Afib with RVR\n (HR=150). She wa started on Zosyn and given Esmolol for rate control,\n though with a drop in her BP= 70/30. Given this hyotension she was\n transferred to the .\n Currently pt c/o L. flank pain, sharp, , nnon-radiating. Also c/o\n R. knee pain, sharp non-radiating (Hx OA). Denies n/v, abd pain. Denies\n chest pain, palpitations, dyspnea, cough, sputum production.\n Patient admitted from: OR / PACU\n History obtained from Patient\n Allergies:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:08 PM\n Infusions:\n Other ICU medications:\n Diltiazem - 01:20 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - Paroxysmal atrial fibrillation, not currently on anticoagulation\n - UC s/p colectomy, with ileostomy\n - Hx SBO though adhesions\n - Osteoarthritis\n - s/p hysterectomy\n - s/p appendectomy\n - former Alcoholic, now sober\n NC\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: former user,\n Other:\n Review of systems:\n Flowsheet Data as of 02:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 132 (126 - 144) bpm\n BP: 139/67(82) {134/67(82) - 139/86(99)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,417 mL\n PO:\n TF:\n IVF:\n 1,117 mL\n Blood products:\n Total out:\n 0 mL\n 325 mL\n Urine:\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,092 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n FiO2: 5L NC\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Thin, Tachypneic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), Tachycardic. No m/r/g\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : )\n Abdominal: Soft, Bowel sounds present, stoma pink.\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): AOx3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 69yo with Hx nephrolithiasis, UC, pAF, now in RVR following stent\n placement for ureteral obstruction.\n Meets criteria for sepsis. Hypotensive in setting of sepsis and RVR.\n Hypoxemic.\n 1. Sepsis ureteral obstruction.\n - Infection source now managed --> s/p placement of ureteral stent.\n Urology team following.\n - Will follow up blood and urine cultures and sensitivities.\n - Currently on Zosyn for presumed GNR coverage. Less likely that\n this is due to gram positive organism.\n - Fluid resuscitate to CVP=, though this will be balanced by\n development of pulmonary edema diastolic dysfunction\n - MAPs >65\n - Will check ScvO2, goal >70%\n 2. Afib with RVR\n - Likely provoked by infection. EKG sans evidence of ACS\n - Rate control with diltiazem; goal HR~80\n - Would initiate anti-platelet therapy; CHADS2= 0, so\n anticoagulation not highly indicated; TTe may be helpful to see if she\n has developed a L. atrial thrombus.\n - Will balance rate control with maintaining adequate blood\n pressures; if unable to maintain pressures can consider cardioversion,\n though certainly this has risks of thromboemboli formation / CVA, given\n Hx pAF.\n 3. Hypoxemia-\n - Likely secondary to edema (given RVR), perhaps atelectasis.\n Unlikely R\nL shunt\n - Will obtain pCXR to r/o pna\n - Keep SpO2>92%\n 3. Acute renal failure\n - likely secondary to obstruction, though could have a pre-renal\n etiology / ATN as well. Cannot exclude AIN given she has been on\n peniciliin agents.\n - Will monitor urine output.\n - Bolus fluid to keep CVP 8-12 as above\n - Renally dose medications and remove offending agents.\n - No indication for RRT currently.\n - urine acidified, to prevent further nephrolithiasis\n formation.\n 4. Acid- base status\n - Chem 7 c/w non-gap hyperchloremic metabolic acidosis. Can check\n urine electrolytes.\n - Patient is tachypneic (approp compensatory response), but doesn;t\n appear to be tiring.\n - Can keep an eye on VBGs obtained through central line.\n 5. Thrombocytopenia\n - Likely infection. Will follow.\n - Check coags to help r/o DIC; if plts decrease can check\n fibrinogen, split dimer products.\n - Pattern not consistent with HIT, no evidence TTP/HUS.\n 6. ICU Issues\n - Diet= clear, advance as tolerated\n - Access= R. IJ TLC. If becomes more hypotensive, may need\n arterial line. Currently no indication.\n - Full Code (d/w patient)\n - Prophylaxis\n + DVT= SQ heparin, SCDs/TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:53 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568324, "text": "Atrial fibrillation (Afib)\n Assessment:\n HR down to 80-100 still in a fib\n Action:\n Monitored for rate changes and homodynamic instability\n Response:\n Cont to be rate controlled\n Plan:\n Cont PO dilt c/o to floor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt admits to min pain this AM\n Action:\n Encouraged PCA use\n Response:\n Tolerable pain level\n Plan:\n Cont to reinforce PCA treatment\n 69 y/o F with a history of A-Fib and total colectomy with illiostomy\n who is s/p L ureteral stent placement r/t renal stone with drainage of\n frank pus on . She developed AFib with RVR post operatively. Pt was\n transferred to M/SICU. On arrival to unit pts HR was 150\ns a-fib,\n received bolus dose of IV diltiazem and started on diltiazem drip.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n SMALL BOWEL OBSTRUCTION\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 69.3 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias\n Additional history: s/p colectomy, with ileostomy, sbo adhesions,\n osteoarthritis, s/p hysterectomy, s/p appendenectomy. alcoholic.,now\n sober\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:58\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 467 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:07 AM\n Potassium:\n 3.8 mEq/L\n 04:07 AM\n Chloride:\n 109 mEq/L\n 04:07 AM\n CO2:\n 18 mEq/L\n 04:07 AM\n BUN:\n 16 mg/dL\n 04:07 AM\n Creatinine:\n 1.3 mg/dL\n 04:07 AM\n Glucose:\n 114 mg/dL\n 04:07 AM\n Hematocrit:\n 29.9 %\n 04:07 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "General", "chartdate": "2103-05-23 00:00:00.000", "description": "Progress note", "row_id": 568355, "text": "TITLE:\n Chief Complaint: AFib w/ RVR\n 24 Hour Events:\n - Weaned off dilt gtt overnight, stable on Pos\n - BCx x 2 with fungus, no speciation\n Allergies:\n Sulfa (Sulfonamides)\n Rash; Shortness\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:43 AM\n Infusions:\n Other ICU medications:\n Diltiazem - 01:20 PM\n Hydromorphone (Dilaudid) - 08:24 PM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.3\nC (99.2\n HR: 98 (71 - 144) bpm\n BP: 103/58(66) {86/47(59) - 140/86(99)} mmHg\n RR: 24 (17 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 65 Inch\n CVP: 11 (10 - 17)mmHg\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 5,937 mL\n 473 mL\n PO:\n 200 mL\n 320 mL\n TF:\n IVF:\n 3,437 mL\n 153 mL\n Blood products:\n Total out:\n 3,968 mL\n 550 mL\n Urine:\n 2,278 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,969 mL\n -77 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///18/\n Physical Examination\n GENERAL - NAD, appropriate\n LUNGS - CTA bilat, no r/rh/wh,\n HEART - PMI non-displaced, RRR, no MRG, nl S1-S2\n ABDOMEN - soft, Generalized TTP/ND, no rebound/guarding, ostomy in\n place.\n EXTREMITIES - WWP, no c/c/e,\n Labs / Radiology\n 134 K/uL\n 9.8 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 109 mEq/L\n 135 mEq/L\n 29.9 %\n 5.0 K/uL\n [image002.jpg]\n 02:17 PM\n 04:07 AM\n WBC\n 5.0\n Hct\n 29.3\n 29.9\n Plt\n 134\n Cr\n 1.5\n 1.3\n Glucose\n 120\n 114\n Other labs: Differential-Neuts:78.5 %, Lymph:14.1 %, Mono:6.1 %,\n Eos:1.1 %, Lactic Acid:1.2 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n 69 y/o F with a history of PAF (off anticoagulation) who is s/p L\n ureteral placement who developed AFib with RVR post operatively\n and was transiently hypotensive.\n .\n #. Afib with RVR: Patient currently hemodynamically stable.\n Ventricular rates currently controlled < 90. Patient does have a\n history of PAF and is currently off anticoagulation. CHADS2 is 0, or 1\n if using age > 65. No echocardiogram in our system, no evidence of\n heart failure on examination.\n - Continue Diltiazem 60mg QID\n - Defer anticoagulation for now, will consider starting ASA 325mg\n - PRN NS Boluses\n - EKG in AM\n - Monitor on telemetry\n .\n #. SIRS/Left obstructed pyelonephritis: Patient is s/p L ureteral\n placement for obstructing stone. Frank pus drained after\n procedure, gram stain negative, showed PMNs. Pt has been on abx.\n Patient was febrile and had RR > 30 intermittantly. CVP is 14. BCx\n with fungemia x 2, but no speciation yet. Patient continued to spike\n temperatures overnight.\n - Continue Zosyn for now\n - Start Micafungin\n - Follow up Urine and Blood Cx for speciation\n - Pain control with Dilaudid PCA\n .\n #. Acute renal sufficiency: Cr 1.3. B/l < 1.0. Likely post\n obstructive renal failure. As patient is s/p ureteral , \n monitor to see resolution in Cr. Patient still has stone, will likely\n pass with placement of .\n - Trend Cr\n - Monitor UOP\n - Renally dose medications\n .\n #. FEN - NPO for now\n .\n #. Access - PIV, R Sublclavian\n .\n #. PPx -\n -DVT ppx with SQ Heparin and PPI\n -Bowel regimen\n -Pain management with Dlaudid PCA\n .\n #. Code - full code\n .\n #. Dispo - Pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568248, "text": "69 y/o F with a history of A-Fib and total colectomy with illiostomy\n who is s/p L ureteral stent placement r/t renal stone with drainage of\n frank pus on . She developed AFib with RVR post operatively. Pt was\n transferred to M/SICU. On arrival to unit pts HR was 150\ns a-fib,\n received bolus dose of IV diltiazem and started on diltiazem drip.\n Sepsis without organ dysfunction\n Assessment:\n Pts temp up to 102.9 at 8 PM.\n BP down from 120\ns -> 80\ns systolic.\n Urine output 30-100cc/hr.\n 02 sats 92-97% on 2L NC, LS clear bilat.\n Green bilious stool draining from ostomy.\n CVP 13-17.\n Action:\n Received 1 L IVF bolus, dilaudid pca dose reduced.\n Received 650mg Tylenol.\n No further cultures ordered as pt was already pan-cultured.\n On IV abx as ordered.\n Ostomy appliance changed.\n Response:\n BP improved following IVF bolus and reduction in PCA dose.\n Temp down to 97.7 following Tylenol, cool bath.\n UO remains adequate.\n Plan:\n Cont to closely monitor pts vitals, urine output, resp status.\n f/u with previous cultures.\n Atrial fibrillation (Afib)\n Assessment:\n At start of shift pts HR 110-130 AF on 15mg/hr of diltiazem.\n Action:\n Received 60mg dose of PO diltiazem at 8 PM.\n Response:\n HR down to 70-80\ns a-fib and drip titrated off at 10 PM.\n 0200 diltiazem dose held r/t SBP 90-100 (MD aware)\n Plan:\n Cont to monitor pts HR.\n Administer PO diltiazem as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n At start of shift pt c/o pain in left flank.\n Little to no relief noted by pt following PCA injections.\n Action:\n MD team made aware of poor pain control.\n Received bolus of 0.5mg dilaudid.\n PCA dose increased.\n Response:\n Pt stated improvement of pain to following increase in dilaudid\n PCA dose.\n Pts became more lethargic, SBP down to 80-90\n Plan:\n PCA dose reduced back to original levels.\n Pts BP improved following reduction in pain meds.\n Pt sleeping comfortably at present.\n Cont to monitor pts pain level.\n" }, { "category": "Nursing", "chartdate": "2103-05-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568319, "text": "Atrial fibrillation (Afib)\n Assessment:\n HR down to 80-100 still in a fib\n Action:\n Monitored for rate changes and homodynamic instability\n Response:\n Cont to be rate controlled\n Plan:\n Cont PO dilt c/o to floor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt admits to min pain this AM\n Action:\n Encouraged PCA use\n Response:\n Tolerable pain level\n Plan:\n Cont to reinforce PCA treatment\n 69 y/o F with a history of A-Fib and total colectomy with illiostomy\n who is s/p L ureteral stent placement r/t renal stone with drainage of\n frank pus on . She developed AFib with RVR post operatively. Pt was\n transferred to M/SICU. On arrival to unit pts HR was 150\ns a-fib,\n received bolus dose of IV diltiazem and started on diltiazem drip.\n" } ]